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General NPI Number Information
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NPI Number | 1255365334
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Entity Type | Individual
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Provider Name | JACK A DEKKINGA MD
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Gender | Male
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Dates
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Enumeration Date | 07/11/2006
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Last Update Date | 02/22/2022
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Provider Practice Location Address
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Address Line | 1673 GEZON PKWY SW
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City | WYOMING
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State | MI
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Zip | 49519-9519
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Country | US
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Telephone | 616-243-3376
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Fax | 616-243-3377
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Provider Business Mailing Address
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Address Line | 1673 GEZON PKWY SW
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City | WYOMING
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State | MI
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Zip | 49519-9519
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Country | US
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Telephone | 616-243-3376
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Fax | 162-433-3776
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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 | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 4301039679
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number | 5601039679
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License Number State | MI
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