Provider Demographics
NPI:1346353471
Name:KOOIKER, NICOLE (DDS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KOOIKER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 CHERRY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4748
Mailing Address - Country:US
Mailing Address - Phone:616-235-7280
Mailing Address - Fax:616-752-4119
Practice Address - Street 1:751 LAFAYETTE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1628
Practice Address - Country:US
Practice Address - Phone:616-742-9941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010181471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID181470OtherBCBS
MI4525391Medicaid
MI4379794Medicaid