Provider Demographics
NPI:1811465990
Name:KINGMA PEDIATRIC DENTISTRY PLLC
Entity type:Organization
Organization Name:KINGMA PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MERREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-551-9701
Mailing Address - Street 1:1179 E PARIS AVE SE STE 130
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3682
Mailing Address - Country:US
Mailing Address - Phone:616-942-9840
Mailing Address - Fax:616-942-0170
Practice Address - Street 1:1179 E PARIS AVE SE STE 130
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3682
Practice Address - Country:US
Practice Address - Phone:616-942-9840
Practice Address - Fax:616-942-0170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty