=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033780184
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KZOO FAMILY DENTAL P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2021
-----------------------------------------------------
Last Update Date | 07/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2334 NAZARETH RD
-----------------------------------------------------
City | KALAMAZOO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49048-1233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-349-6262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2334 NAZARETH RD
-----------------------------------------------------
City | KALAMAZOO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49048-1233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-349-6262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INSURANCE SPECIALIST
-----------------------------------------------------
Name | RENEE HEISE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 231-246-2204
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------