1275914673 NPI number — 44 WEST DENTAL PROFESSIONALS PC

Table of content: (NPI 1275914673)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275914673 NPI number — 44 WEST DENTAL PROFESSIONALS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
44 WEST DENTAL PROFESSIONALS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275914673
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4330 44TH ST SW STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRANDVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49418-2349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-530-2200
Provider Business Mailing Address Fax Number:
616-530-8250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4330 44TH ST SW STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANDVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49418-2349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-530-2200
Provider Business Practice Location Address Fax Number:
616-530-8250
Provider Enumeration Date:
06/11/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DOUBLESTEIN
Authorized Official First Name:
JASON
Authorized Official Middle Name:
C
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
616-530-2200

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  2901018806 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 122300000X , with the licence number: 2901020644 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1386760072 . This is a "DENTIST" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1760829444 . This is a "DENTIST" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1578823993 . This is a "DENTIST" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".