Healthcare Provider Details

I. General information

NPI: 1336409358
Provider Name (Legal Business Name): NICHOLE BRINKMAN LUBBERTS D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 5 MILE RD NE #202
GRAND RAPIDS MI
49525-6516
US

IV. Provider business mailing address

2700 5 MILE RD NE #202
GRAND RAPIDS MI
49525-6516
US

V. Phone/Fax

Practice location:
  • Phone: 813-951-1716
  • Fax:
Mailing address:
  • Phone: 813-951-1716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN19882
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901021313
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: