Provider Demographics
NPI:1942327259
Name:WEST MICHIGAN PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:WEST MICHIGAN PEDIATRIC DENTISTRY
Other - Org Name:WEST MICHIGAN PEDATRIC DENTISTRY, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:WISSINK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-392-2381
Mailing Address - Street 1:845 E. 16TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423
Mailing Address - Country:US
Mailing Address - Phone:616-392-2381
Mailing Address - Fax:616-392-3748
Practice Address - Street 1:845 E. 16TH ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423
Practice Address - Country:US
Practice Address - Phone:616-392-2381
Practice Address - Fax:616-392-3748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010123231223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4383590-12Medicaid
MI4383607-12Medicaid