Healthcare Provider Details

I. General information

NPI: 1962830794
Provider Name (Legal Business Name): JERRY BURGESS MULDER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2013
Last Update Date: 10/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 MICHIGAN ST NE STE 207
GRAND RAPIDS MI
49503-5608
US

IV. Provider business mailing address

426 MICHIGAN ST NE STE 207
GRAND RAPIDS MI
49503-5608
US

V. Phone/Fax

Practice location:
  • Phone: 616-458-0631
  • Fax:
Mailing address:
  • Phone: 616-458-0631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. JERRY BURGESS MULDE4R
Title or Position: DENTIST
Credential: DDS
Phone: 616-458-0631