Provider Demographics
NPI:1093716706
Name:RENZEMA, ROBERT D (DDS)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:D
Last Name:RENZEMA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4721
Mailing Address - Country:US
Mailing Address - Phone:616-396-8320
Mailing Address - Fax:616-396-8764
Practice Address - Street 1:532 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4721
Practice Address - Country:US
Practice Address - Phone:616-396-8320
Practice Address - Fax:616-396-8764
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI8507122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4022150Medicaid