Healthcare Provider Details

I. General information

NPI: 1831702695
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY OF MICHIGAN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2020
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3297 EAGLE RUN DR NE
GRAND RAPIDS MI
49525-7050
US

IV. Provider business mailing address

3297 EAGLE RUN DR NE
GRAND RAPIDS MI
49525-7050
US

V. Phone/Fax

Practice location:
  • Phone: 917-597-6749
  • Fax:
Mailing address:
  • Phone: 917-597-6749
  • 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. WANKI KIM
Title or Position: OWNER
Credential: DDS
Phone: 917-597-6749