Healthcare Provider Details

I. General information

NPI: 1669864732
Provider Name (Legal Business Name): BRETT KINGMA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2015
Last Update Date: 02/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1179 E PARIS AVE SE
GRAND RAPIDS MI
49546-8371
US

IV. Provider business mailing address

1392 CLERMONT ST
DENVER CO
80220-2440
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-9840
  • Fax: 616-942-0170
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2901021450
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: