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General NPI Number Information
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NPI Number | 1164680971
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Entity Type | Organization
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Legal Business Name | DENTAL GROUP WEST, P.C.
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Dates
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Enumeration Date | 05/29/2008
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Last Update Date | 05/29/2008
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Provider Practice Location Address
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Address Line | 1063 4 MILE RD NW
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City | GRAND RAPIDS
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State | MI
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Zip | 49544-7398
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Country | US
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Telephone | 616-785-3344
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Fax | 616-785-4013
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Provider Business Mailing Address
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Address Line | 1063 4 MILE RD NW
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City | GRAND RAPIDS
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State | MI
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Zip | 49544-7398
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Country | US
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Telephone | 616-785-3344
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Fax | 616-785-4013
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Authorized Official
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Title or Position | PRESIDENT
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Name | RICKEY L VAN SWEDEN
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Credential |
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Telephone | 616-785-3344
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2901010289
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License Number State | MI
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