Healthcare Provider Details

I. General information

NPI: 1275987752
Provider Name (Legal Business Name): BELMONT DENTISTRY PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 04/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1259 POST DR NE STE E
BELMONT MI
49306-8717
US

IV. Provider business mailing address

1259 POST DR NE STE E
BELMONT MI
49306-8717
US

V. Phone/Fax

Practice location:
  • Phone: 616-284-3200
  • Fax:
Mailing address:
  • Phone: 616-284-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901017901
License Number StateMI

VIII. Authorized Official

Name: DR. JOHN KLOOSTER
Title or Position: SOLE MEMBER
Credential: DDS
Phone: 616-284-3200