Healthcare Provider Details

I. General information

NPI: 1629982939
Provider Name (Legal Business Name): FRESH COAST PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 3 MILE RD NW STE 102
GRAND RAPIDS MI
49544-1673
US

IV. Provider business mailing address

820 GLADSTONE DR SE
GRAND RAPIDS MI
49506-3334
US

V. Phone/Fax

Practice location:
  • Phone: 616-606-3811
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. TARYN WEIL
Title or Position: OWNER
Credential: DDS
Phone: 616-606-3811