Healthcare Provider Details

I. General information

NPI: 1316667462
Provider Name (Legal Business Name): ROOT CANAL SPECIALISTS NORTH, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4355 SAWKAW DR. NE
GRAND RAPIDS MI
49525-1768
US

IV. Provider business mailing address

4355 SAWKAW DR. NE
GRAND RAPIDS MI
49525-1768
US

V. Phone/Fax

Practice location:
  • Phone: 616-361-6609
  • Fax: 616-361-6248
Mailing address:
  • Phone: 616-361-6609
  • Fax: 616-361-6248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. JACK KEMPER
Title or Position: ENDODONTICS/C.F.O.
Credential: D.M.D
Phone: 616-361-6609