Provider Demographics
NPI:1194204636
Name:ROBERT DALE RENZEMA
Entity Type:Organization
Organization Name:ROBERT DALE RENZEMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:RENZEMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-396-8320
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
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROBERT D RENZEMA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-07
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901008507261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental