Provider Demographics
NPI:1679855761
Name:MODERN PERIODONTICS
Entity Type:Organization
Organization Name:MODERN PERIODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:MOERDYKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-241-5658
Mailing Address - Street 1:2356 32ND STREET
Mailing Address - Street 2:SUITE #100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508
Mailing Address - Country:US
Mailing Address - Phone:616-241-5658
Mailing Address - Fax:
Practice Address - Street 1:2356 32ND STREET
Practice Address - Street 2:SUITE #100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-1510
Practice Address - Country:US
Practice Address - Phone:616-241-5658
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI167911223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty