Provider Demographics
NPI:1609111202
Name:DYNAMITE HEARING CONSULTANTS, LLC
Entity Type:Organization
Organization Name:DYNAMITE HEARING CONSULTANTS, LLC
Other - Org Name:MIRACLE-EAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER; HEARING INSTRUMENT SPECIALIS
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:NORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:HIS
Authorized Official - Phone:616-538-5300
Mailing Address - Street 1:1000 3 MILE RD NW
Mailing Address - Street 2:SUITE D
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-1650
Mailing Address - Country:US
Mailing Address - Phone:616-538-5300
Mailing Address - Fax:
Practice Address - Street 1:1000 3 MILE RD NW
Practice Address - Street 2:SUITE D
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-1650
Practice Address - Country:US
Practice Address - Phone:616-538-5300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-07
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3501004919237700000X
MI3501005725237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty