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General NPI Number Information
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NPI Number | 1831702695
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DENTISTRY OF MICHIGAN PLLC
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Dates
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Enumeration Date | 08/30/2020
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Last Update Date | 01/25/2021
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Provider Practice Location Address
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Address Line | 3297 EAGLE RUN DR NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49525-7050
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Country | US
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Telephone | 917-597-6749
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Fax |
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Provider Business Mailing Address
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Address Line | 3297 EAGLE RUN DR NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49525-7050
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Country | US
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Telephone | 917-597-6749
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. WANKI KIM
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Credential | DDS
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Telephone | 917-597-6749
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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