Healthcare Provider Details

I. General information

NPI: 1407349012
Provider Name (Legal Business Name): ALICIA RANAE NIEUWKOOP DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2018
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56720 CALUMET AVE
CALUMET MI
49913-1967
US

IV. Provider business mailing address

301 EXPLORER ST
GWINN MI
49841-2813
US

V. Phone/Fax

Practice location:
  • Phone: 906-483-1177
  • Fax:
Mailing address:
  • Phone: 906-346-4924
  • Fax: 906-346-6474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901022628
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: