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General NPI Number Information
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NPI Number | 1043628670
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Entity Type | Individual
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Provider Name | BRENT A MEDEMA D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 07/28/2014
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Last Update Date | 07/28/2014
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Provider Practice Location Address
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Address Line | 9021 N RODGERS CT SE SUITE E
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City | CALEDONIA
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State | MI
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Zip | 49316-7649
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Country | US
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Telephone | 616-891-1400
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Fax |
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Provider Business Mailing Address
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Address Line | 7090 HICKORY POINT DR
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City | PORTAGE
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State | MI
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Zip | 49024-4039
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Country | US
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Telephone | 269-760-5505
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 2901021310
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License Number State | MI
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