Provider Demographics
NPI:1639440233
Name:GARY L ZOUTENDAM DDS PC
Entity Type:Organization
Organization Name:GARY L ZOUTENDAM DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:ZOUTENDAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-962-8505
Mailing Address - Street 1:491 E. COLUMBIA AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49014-5468
Mailing Address - Country:US
Mailing Address - Phone:269-962-8505
Mailing Address - Fax:269-962-9160
Practice Address - Street 1:491 E. COLUMBIA AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49014-5468
Practice Address - Country:US
Practice Address - Phone:269-962-8505
Practice Address - Fax:269-962-9160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-13
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901016510122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2990454Medicaid
MI51377398972Medicare UPIN
MI2990454Medicaid