Organization
MODERN PERIODONTICS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. ERIN NICOLE MOERDYKE (OFFICE MANAGER)
(616) 241-5658
Entity
Organization
Contact information
Practice address
2356 32ND STREET, SUITE #100, GRAND RAPIDS, MI 49508-1510
(616) 241-5658
Mailing address
2356 32ND STREET, SUITE #100, GRAND RAPIDS, MI 49508
(616) 241-5658
Taxonomy
Speciality
Code
Description
License number
State
1223P0300X
Periodontics
Primary
16791
MI
Other
Enumeration date
09/14/2011
Last updated
09/14/2011
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