Provider Demographics
NPI:1003573403
Name:OUDERKIRK DENTAL PLLC
Entity Type:Organization
Organization Name:OUDERKIRK DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OUDERKIRK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:517-917-1836
Mailing Address - Street 1:1028 GRENOBLE CIR
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-4811
Mailing Address - Country:US
Mailing Address - Phone:517-917-1836
Mailing Address - Fax:
Practice Address - Street 1:11970 SWEETWATER DR
Practice Address - Street 2:
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-8199
Practice Address - Country:US
Practice Address - Phone:517-627-2470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty