Provider Demographics
NPI:1972679504
Name:DWIGHT J MONSMA DDS PC
Entity Type:Organization
Organization Name:DWIGHT J MONSMA DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:EWA
Authorized Official - Middle Name:BARBARA
Authorized Official - Last Name:OSTROWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-942-9891
Mailing Address - Street 1:3521 LAKE EASTBROOK BLVD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546
Mailing Address - Country:US
Mailing Address - Phone:616-942-9891
Mailing Address - Fax:616-942-9894
Practice Address - Street 1:3521 LAKE EASTBROOK BLVD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-942-9891
Practice Address - Fax:616-942-9891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901008106122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4063994Medicaid