Healthcare Provider Details

I. General information

NPI: 1033223250
Provider Name (Legal Business Name): ORAL SURGERY ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 01/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2144 E PARIS AVE SE STE 150
GRAND RAPIDS MI
49546-6126
US

IV. Provider business mailing address

2144 E PARIS AVE SE STE 150
GRAND RAPIDS MI
49546-6126
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-2000
  • Fax: 616-942-6805
Mailing address:
  • Phone: 616-942-2000
  • Fax: 616-942-6805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. KENNETH J MULDER
Title or Position: PRESIDENT
Credential: DDS, MS
Phone: 616-942-2000