Provider Demographics
NPI:1528193745
Name:KOOISTRA, RALPH ANDREW JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:RALPH
Middle Name:ANDREW
Last Name:KOOISTRA
Suffix:JR
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 1:795 NAGASHI DR
Mailing Address - Street 2:
Mailing Address - City:EAST JORDAN
Mailing Address - State:MI
Mailing Address - Zip Code:49727-9492
Mailing Address - Country:US
Mailing Address - Phone:231-536-3032
Mailing Address - Fax:
Practice Address - Street 1:3096 WEST M-32 HWY
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735
Practice Address - Country:US
Practice Address - Phone:989-731-2087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI162241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice