Healthcare Provider Details

I. General information

NPI: 1972679504
Provider Name (Legal Business Name): DWIGHT J MONSMA DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3521 LAKE EASTBROOK BLVD SE
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

3521 LAKE EASTBROOK BLVD SE
GRAND RAPIDS MI
49546
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-9891
  • Fax: 616-942-9891
Mailing address:
  • Phone: 616-942-9891
  • Fax: 616-942-9894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901008106
License Number StateMI

VIII. Authorized Official

Name: MS. EWA BARBARA OSTROWSKI
Title or Position: BUSINESS ADMINISTRATOR
Credential:
Phone: 616-942-9891