# GRAND RIVER FAMILY DENTISTRY P.C.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1467401141
- **Authorized official:** DR. ABRAHAM LAWRENCE AZZOUZ D.D.S. (PRESIDENT DENTIST)
- **Authorized official phone:** (313) 535-2273

## Contact information

- **Practice address:** 24366 GRAND RIVER AVE, SUITE 111, DETROIT, MI 48219-3063
- **Practice address phone:** (313) 535-2273
- **Practice address fax:** (313) 535-5212
- **Mailing address:** 24366 GRAND RIVER AVE, SUITE 111, DETROIT, MI 48219-3063
- **Mailing address phone:** (313) 535-2273
- **Mailing address fax:** (313) 535-5212

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | 2901015675 | MI | Yes |

## Other

- **Enumeration date:** 05/09/2006
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 3197750 | — | MI |
| 01 | — | 873745 | UNITED CONCORDIA | MI |
| 01 | — | BA2373443 | U.S. D.E.A. | — |
| 01 | — | D800185 | BLUE CROSS BLUE SHEILD | MI |