Provider Demographics
NPI:1376999433
Name:WEST SIDE DENTAL PC
Entity Type:Organization
Organization Name:WEST SIDE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLYSON
Authorized Official - Middle Name:BURGESS
Authorized Official - Last Name:MULDER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:616-453-5331
Mailing Address - Street 1:515 MICHIGAN ST NE STE 202
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5721
Mailing Address - Country:US
Mailing Address - Phone:616-453-5331
Mailing Address - Fax:616-453-9235
Practice Address - Street 1:515 MICHIGAN ST NE STE 202
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5721
Practice Address - Country:US
Practice Address - Phone:616-453-5331
Practice Address - Fax:616-453-9235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-09
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010207491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty