Provider Demographics
NPI:1962830794
Name:JERRY BURGESS MULDER
Entity Type:Organization
Organization Name:JERRY BURGESS MULDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:BURGESS
Authorized Official - Last Name:MULDE4R
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-458-0631
Mailing Address - Street 1:426 MICHIGAN ST NE STE 207
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5608
Mailing Address - Country:US
Mailing Address - Phone:616-458-0631
Mailing Address - Fax:
Practice Address - Street 1:426 MICHIGAN ST NE STE 207
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5608
Practice Address - Country:US
Practice Address - Phone:616-458-0631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-14
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies