Provider Demographics
NPI:1073153979
Name:OROURKE AND WONDERLY DENTAL
Entity Type:Organization
Organization Name:OROURKE AND WONDERLY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LORA
Authorized Official - Middle Name:
Authorized Official - Last Name:WONDERLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-455-7930
Mailing Address - Street 1:4250 KALAMAZOO AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-2699
Mailing Address - Country:US
Mailing Address - Phone:616-455-7930
Mailing Address - Fax:616-455-9952
Practice Address - Street 1:4250 KALAMAZOO AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-2699
Practice Address - Country:US
Practice Address - Phone:616-455-7930
Practice Address - Fax:616-455-9952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty