Healthcare Provider Details

I. General information

NPI: 1730440983
Provider Name (Legal Business Name): IGOR MAKOVEY D.D.S., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2012
Last Update Date: 08/29/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 CASCADE RD SE STE 208
GRAND RAPIDS MI
49546-3665
US

IV. Provider business mailing address

4500 CASCADE RD SE STE 208
GRAND RAPIDS MI
49546-3665
US

V. Phone/Fax

Practice location:
  • Phone: 616-977-5000
  • Fax: 616-977-0020
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901015669
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4301117131
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: