MEDICARE: DR. JEFFREY T HUISMAN D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	18263	MI

General Provider Information

NPI Number	:	1154452092
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY T HUISMAN D.D.S.

Provider Business Mailing Address
First Line	:	397 120TH AVE
Second Line	:
City	:	HOLLAND
State	:	MI
Zip	:	49424-2118
Country	:	US
Telephone Number	:	616-396-5919
Fax Number	:	616-396-9995

Provider Business Practice Location Address
First Line	:	397 120TH AVE
Second Line	:
City	:	HOLLAND
State	:	MI
Zip	:	49424-2118
Country	:	US
Telephone Number	:	616-396-5919
Fax Number	:	616-396-9995

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	09/11/2007

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