MEDICARE: DENTAL GROUP WEST, P.C.

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	2901010289	MI

General Provider Information

NPI Number	:	1164680971
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL GROUP WEST, P.C.

Provider Business Mailing Address
First Line	:	1063 4 MILE RD NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49544-7398
Country	:	US
Telephone Number	:	616-785-3344
Fax Number	:	616-785-4013

Provider Business Practice Location Address
First Line	:	1063 4 MILE RD NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49544-7398
Country	:	US
Telephone Number	:	616-785-3344
Fax Number	:	616-785-4013

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RICKEY L VAN SWEDEN
Credential	:
Telephone Number	:	616-785-3344

Provider Enumeration Date	:	05/29/2008
Last Update Date	:	05/29/2008

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