=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427594027
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEL TROTTER MINISTRIES DENTAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2017
-----------------------------------------------------
Last Update Date | 01/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 COMMERCE AVE SW
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49503-4107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-588-8796
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 225 COMMERCE AVE SW
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49503-4107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-588-8796
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MR. GORDON OOSTING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 616-588-8773
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------