| NPI | 1962815605 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BRADLEY A DYKSTRA Owner 616-669-6600 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 11799) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 12554) |
| 122300000X Dentist (Licence: MI 18713) | |
| 122300000X Dentist (Licence: MI 19719) | |
| Enumeration Date | 2014-06-10 |
| Last Update Date | 2014-06-10 |