Healthcare Provider Details

I. General information

NPI: 1174974356
Provider Name (Legal Business Name): OCULOPLASTIC ASSOCIATES OF WEST MICHIGAN, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2016
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4070 LAKE DR SE SUITE 205
GRAND RAPIDS MI
49546-8294
US

IV. Provider business mailing address

4070 LAKE DR SE SUITE 205
GRAND RAPIDS MI
49546-8294
US

V. Phone/Fax

Practice location:
  • Phone: 616-888-2948
  • Fax: 616-888-2949
Mailing address:
  • Phone: 616-888-2948
  • Fax: 616-888-2949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number4301092933
License Number StateMI

VIII. Authorized Official

Name: TIFFANY L KENT
Title or Position: OWNER, PHYSICIAN
Credential: MD, PHD
Phone: 616-888-2948