Healthcare Provider Details

I. General information

NPI: 1609111202
Provider Name (Legal Business Name): DYNAMITE HEARING CONSULTANTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2012
Last Update Date: 12/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 3 MILE RD NW SUITE D
GRAND RAPIDS MI
49544-1650
US

IV. Provider business mailing address

1000 3 MILE RD NW SUITE D
GRAND RAPIDS MI
49544-1650
US

V. Phone/Fax

Practice location:
  • Phone: 616-538-5300
  • Fax:
Mailing address:
  • Phone: 616-538-5300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number3501005725
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number3501004919
License Number StateMI

VIII. Authorized Official

Name: MR. BENJAMIN NORRIS
Title or Position: OWNER; HEARING INSTRUMENT SPECIALIS
Credential: H.I.S.
Phone: 616-538-5300