Provider Demographics
NPI:1639797640
Name:KOOLWICK, KADIE ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KADIE
Middle Name:ANN
Last Name:KOOLWICK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5873 KINGSFIELD DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-1479
Mailing Address - Country:US
Mailing Address - Phone:248-996-7645
Mailing Address - Fax:
Practice Address - Street 1:5500 NORTHLAND DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1064
Practice Address - Country:US
Practice Address - Phone:616-364-9451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901600589122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist