Provider Demographics
NPI:1184194433
Name:PEDIATRIC DENTAL SPECIALISTS OF WEST MICHIGAN
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL SPECIALISTS OF WEST MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-705-3285
Mailing Address - Street 1:717 CROSWELL AVE SE
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-3005
Mailing Address - Country:US
Mailing Address - Phone:248-705-3285
Mailing Address - Fax:
Practice Address - Street 1:2155 E PARIS AVE SE STE 120
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6142
Practice Address - Country:US
Practice Address - Phone:616-608-8898
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty