Healthcare Provider Details

I. General information

NPI: 1013099092
Provider Name (Legal Business Name): KAREN A O ROURKE DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4250 KALAMAZOO SE STE 1
GRAND RAPIDS MI
49508-3607
US

IV. Provider business mailing address

4250 KALAMAZOO SE STE 1
GRAND RAPIDS MI
49508-3607
US

V. Phone/Fax

Practice location:
  • Phone: 616-455-7930
  • Fax: 616-455-9952
Mailing address:
  • Phone: 616-455-7930
  • Fax: 616-455-9952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901014123
License Number StateMI

VIII. Authorized Official

Name: DR. KAREN A O ROURKE
Title or Position: DENTIST PRESIDENT
Credential: DDS
Phone: 616-455-7930