MEDICARE: MODERN PERIODONTICS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	16791	MI

General Provider Information

NPI Number	:	1679855761
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN PERIODONTICS

Provider Business Mailing Address
First Line	:	2356 32ND STREET
Second Line	:	SUITE #100
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508
Country	:	US
Telephone Number	:	616-241-5658
Fax Number	:

Provider Business Practice Location Address
First Line	:	2356 32ND STREET
Second Line	:	SUITE #100
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-1510
Country	:	US
Telephone Number	:	616-241-5658
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. ERIN NICOLE MOERDYKE
Credential	:
Telephone Number	:	616-241-5658

Provider Enumeration Date	:	09/14/2011
Last Update Date	:	09/14/2011

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