=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073909297
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARMBRECHT & WIERENGA ORTHODONTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2015
-----------------------------------------------------
Last Update Date | 04/30/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3131 44TH ST SW
-----------------------------------------------------
City | GRANDVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49418-2684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-301-8900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3131 44TH ST SW
-----------------------------------------------------
City | GRANDVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49418-2684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-301-8900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORTHODONTIST
-----------------------------------------------------
Name | DR. MARK WIERENGA
-----------------------------------------------------
Credential | DDS, MS
-----------------------------------------------------
Telephone | 616-301-8900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 2901020872
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------