Healthcare Provider Details

I. General information

NPI: 1275520199
Provider Name (Legal Business Name): MARK W TOURNELL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5010 CASCADE RD SE
GRAND RAPIDS MI
49546-3725
US

IV. Provider business mailing address

5010 CASCADE RD SE
GRAND RAPIDS MI
49546-3725
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-0840
  • Fax: 616-348-0899
Mailing address:
  • Phone: 616-942-0840
  • Fax: 616-942-0899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11639
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: