Healthcare Provider Details

I. General information

NPI: 1639797640
Provider Name (Legal Business Name): KADIE ANN KOOLWICK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 NORTHLAND DR NE
GRAND RAPIDS MI
49525-1064
US

IV. Provider business mailing address

5873 KINGSFIELD DR
WEST BLOOMFIELD MI
48322-1479
US

V. Phone/Fax

Practice location:
  • Phone: 616-364-9451
  • Fax:
Mailing address:
  • Phone: 248-996-7645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901600589
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: