Provider Demographics
NPI:1225131782
Name:ZOUTENDAM, GARY LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:ZOUTENDAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:491 E COLUMBIA AVE
Mailing Address - Street 2:STE 3
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015
Mailing Address - Country:US
Mailing Address - Phone:269-962-8505
Mailing Address - Fax:269-962-9160
Practice Address - Street 1:491 E COLUMBIA AVE
Practice Address - Street 2:STE 3
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015
Practice Address - Country:US
Practice Address - Phone:269-962-8505
Practice Address - Fax:269-962-9160
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGZ105101223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4045261Medicaid
MIT82980Medicare ID - Type Unspecified