Healthcare Provider Details

I. General information

NPI: 1346353471
Provider Name (Legal Business Name): NICOLE KOOIKER D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 LAFAYETTE AVE NE
GRAND RAPIDS MI
49503-1628
US

IV. Provider business mailing address

550 CHERRY ST SE
GRAND RAPIDS MI
49503-4748
US

V. Phone/Fax

Practice location:
  • Phone: 616-742-9941
  • Fax:
Mailing address:
  • Phone: 616-235-7280
  • Fax: 616-752-4119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901018147
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: