Healthcare Provider Details

I. General information

NPI: 1912062902
Provider Name (Legal Business Name): MARK ALLAN OSENIEKS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 06/22/2020
Certification Date: 06/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

O-11225 TALLMADGE WOODS DR NW
GRAND RAPIDS MI
49534-6313
US

IV. Provider business mailing address

11225 TALLMADGE WOODS DR NW
GRAND RAPIDS MI
49534-6306
US

V. Phone/Fax

Practice location:
  • Phone: 616-453-0002
  • Fax:
Mailing address:
  • Phone: 616-453-0002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901016297
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: