1073506390 NPI number — DR. JEFFREY ALLEN LINDHOUT DDS MS

Table of content: DR. JEFFREY ALLEN LINDHOUT DDS MS (NPI 1073506390)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073506390 NPI number — DR. JEFFREY ALLEN LINDHOUT DDS MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LINDHOUT
Provider First Name:
JEFFREY
Provider Middle Name:
ALLEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS MS
Provider Gender Code:
M

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:
1073506390
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2007
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
Provider Second Line Business Mailing Address:
SUITE 106
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:
616-530-4710
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4330 44TH ST SW
Provider Second Line Business Practice Location Address:
SUITE 106
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:
616-530-4710
Provider Business Practice Location Address Fax Number:
616-530-0480
Provider Enumeration Date:
08/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  2901015336 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3057811 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3057820 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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