Healthcare Provider Details

I. General information

NPI: 1295094563
Provider Name (Legal Business Name): JACK KOU D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6221 W PIERSON RD
FLUSHING MI
48433-2338
US

IV. Provider business mailing address

6221 W PIERSON RD
FLUSHING MI
48433-2338
US

V. Phone/Fax

Practice location:
  • Phone: 810-733-2700
  • Fax:
Mailing address:
  • Phone: 810-733-2700
  • Fax: 810-733-3638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901601605
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: