Healthcare Provider Details

I. General information

NPI: 1790886448
Provider Name (Legal Business Name): LEE D ZUIDEMA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6677 CROSSINGS DR SE
GRAND RAPIDS MI
49508-7889
US

IV. Provider business mailing address

6677 CROSSINGS DR SE
GRAND RAPIDS MI
49508-7889
US

V. Phone/Fax

Practice location:
  • Phone: 616-656-2400
  • Fax: 616-656-2424
Mailing address:
  • Phone: 616-656-2400
  • Fax: 616-656-2424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number128770
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: