Healthcare Provider Details

I. General information

NPI: 1225131782
Provider Name (Legal Business Name): GARY LEE ZOUTENDAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 06/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

491 E COLUMBIA AVE STE 3
BATTLE CREEK MI
49015
US

IV. Provider business mailing address

491 E COLUMBIA AVE STE 3
BATTLE CREEK MI
49015
US

V. Phone/Fax

Practice location:
  • Phone: 269-962-8505
  • Fax: 269-962-9160
Mailing address:
  • Phone: 269-962-8505
  • Fax: 269-962-9160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberGZ10510
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: