NPIMap

Organization Active NPI

Grand Lake Family Dentistry, LTD.

  • Dentist
  • Celina, OH
National Provider Identifier
1952428310
Registry record updated May 20, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
License
30.020826 Issued in OH
Legal business name
GRAND LAKE FAMILY DENTISTRY, LTD.
Practice address
800 E Wayne St
Celina, OH 45822-1359
Phone
(419) 586-1615
Fax
(419) 586-1616
NPI assigned
Mar 23, 2007
Last updated
May 20, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 20, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Travis Duane Lutz, DDSNPI 1295852655
Title
President
Phone
(419) 586-1615

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dentist 122300000X 30.020826 OH Primary

Addresses

Primary practice location

800 E Wayne St
Celina, OH 45822-1359

Mailing address

800 E Wayne St
PO Box 316
Celina, OH 45822-1359
Phone (419) 586-1615

Other identifiers 3

IdentifierTypeStateIssuer
06131OtherPARAMOUNT
2057965MedicaidOH
9182631OtherDENTAQUEST

National Provider Directory

National Provider Directory

Locations

800 E Wayne St
Celina, OH 45822
Phone (419) 586-1615

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1174608000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1747699200000",
    "number": "1952428310",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "800 E WAYNE ST",
            "address_2": "PO BOX 316",
            "city": "CELINA",
            "state": "OH",
            "postal_code": "458221359",
            "telephone_number": "419-586-1615",
            "fax_number": "419-586-1616"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "800 E WAYNE ST",
            "city": "CELINA",
            "state": "OH",
            "postal_code": "458221359",
            "telephone_number": "419-586-1615",
            "fax_number": "419-586-1616"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GRAND LAKE FAMILY DENTISTRY, LTD.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-23",
        "last_updated": "2025-05-20",
        "certification_date": "2025-05-20",
        "status": "A",
        "authorized_official_last_name": "LUTZ",
        "authorized_official_first_name": "TRAVIS",
        "authorized_official_middle_name": "DUANE",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "419-586-1615",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "OH",
            "license": "30.020826",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PARAMOUNT",
            "identifier": "06131",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2057965",
            "state": "OH"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DENTAQUEST",
            "identifier": "9182631",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Celina, OH

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 20, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.