Healthcare Provider Details

I. General information

NPI: 1184194433
Provider Name (Legal Business Name): PEDIATRIC DENTAL SPECIALISTS OF WEST MICHIGAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 E PARIS AVE SE STE 120
GRAND RAPIDS MI
49546-6142
US

IV. Provider business mailing address

717 CROSWELL AVE SE
EAST GRAND RAPIDS MI
49506-3005
US

V. Phone/Fax

Practice location:
  • Phone: 616-608-8898
  • Fax:
Mailing address:
  • Phone: 248-705-3285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. KATHRYN L SWANSON
Title or Position: PEDIATRIC DENTIST
Credential:
Phone: 248-705-3285