Provider Demographics
NPI:1275914673
Name:44 WEST DENTAL PROFESSIONALS PC
Entity Type:Organization
Organization Name:44 WEST DENTAL PROFESSIONALS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:C
Authorized Official - Last Name:DOUBLESTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-530-2200
Mailing Address - Street 1:4330 44TH ST SW STE 105
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2349
Mailing Address - Country:US
Mailing Address - Phone:616-530-2200
Mailing Address - Fax:616-530-8250
Practice Address - Street 1:4330 44TH ST SW STE 105
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2349
Practice Address - Country:US
Practice Address - Phone:616-530-2200
Practice Address - Fax:616-530-8250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-11
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901018806122300000X
MI2901020644122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1386760072OtherDENTIST
MI1760829444OtherDENTIST
MI1578823993OtherDENTIST