Healthcare Provider Details

I. General information

NPI: 1457570863
Provider Name (Legal Business Name): GADIA KUMUNJUN PEABODY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 S GETTY ST
MUSKEGON MI
49444-1207
US

IV. Provider business mailing address

2201 S GETTY ST
MUSKEGON MI
49444-1207
US

V. Phone/Fax

Practice location:
  • Phone: 231-767-9830
  • Fax: 231-737-1808
Mailing address:
  • Phone: 231-767-9830
  • Fax: 231-737-1808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019026130
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number63907
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number2901011507
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: