Healthcare Provider Details

I. General information

NPI: 1073153979
Provider Name (Legal Business Name): OROURKE AND WONDERLY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4250 KALAMAZOO AVE SE
GRAND RAPIDS MI
49508-2699
US

IV. Provider business mailing address

4250 KALAMAZOO AVE SE
GRAND RAPIDS MI
49508-2699
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 Number
License Number State

VIII. Authorized Official

Name: DR. LORA WONDERLY
Title or Position: DENTIST
Credential: DDS
Phone: 616-455-7930