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General NPI Number Information
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NPI Number | 1942327259
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Entity Type | Organization
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Legal Business Name | WEST MICHIGAN PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 03/23/2007
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Last Update Date | 09/24/2021
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Provider Practice Location Address
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Address Line | 845 E. 16TH ST
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City | HOLLAND
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State | MI
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Zip | 49423
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Country | US
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Telephone | 616-392-2381
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Fax | 616-392-3748
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Provider Business Mailing Address
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Address Line | 845 E. 16TH ST
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City | HOLLAND
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State | MI
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Zip | 49423
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Country | US
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Telephone | 616-392-2381
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Fax | 616-392-3748
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | KATHY WISSINK
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Credential |
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Telephone | 616-392-2381
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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 | 2901012323
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License Number State | MI
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