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General NPI Number Information
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NPI Number | 1073153979
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Entity Type | Organization
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Legal Business Name | OROURKE AND WONDERLY DENTAL
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Dates
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Enumeration Date | 01/09/2020
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Last Update Date | 01/09/2020
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Provider Practice Location Address
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Address Line | 4250 KALAMAZOO AVE SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49508-2699
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Country | US
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Telephone | 616-455-7930
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Fax | 616-455-9952
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Provider Business Mailing Address
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Address Line | 4250 KALAMAZOO AVE SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49508-2699
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Country | US
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Telephone | 616-455-7930
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Fax | 616-455-9952
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Authorized Official
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Title or Position | DENTIST
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Name | DR. LORA WONDERLY
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Credential | DDS
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Telephone | 616-455-7930
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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