Provider Demographics
NPI:1356454409
Name:KOOIKER, KEVIN (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:KOOIKER
Suffix:
Gender:M
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 1:101 SHELDON BLVD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4262
Practice Address - Country:US
Practice Address - Phone:616-776-2340
Practice Address - Fax:616-776-2341
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
MI29010179021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4525382Medicaid
MI4535790Medicaid
MID179020OtherBCBS