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General NPI Number Information
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NPI Number | 1164484705
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Entity Type | Individual
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Provider Name | LEON JAMES BANGMA OD
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Gender | Male
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Dates
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Enumeration Date | 04/06/2006
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Last Update Date | 10/29/2007
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Provider Practice Location Address
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Address Line | 2897 RADCLIFF AVE SE
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City | KENTWOOD
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State | MI
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Zip | 49512-1793
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Country | US
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Telephone | 616-942-2710
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Fax | 616-942-8680
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Provider Business Mailing Address
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Address Line | 105 W EXCHANGE ST
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City | SPRING LAKE
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State | MI
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Zip | 49456-2024
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Country | US
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Telephone | 616-846-0620
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 4901002511
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License Number State | MI
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