Basic Information
| Provider Information | |||||||||
| NPI: | 1346353471 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOOIKER | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.D.S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 CHERRY ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162357280 | ||||||||
| FaxNumber: | 6167524119 | ||||||||
| Practice Location | |||||||||
| Address1: | 751 LAFAYETTE AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495031628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167429941 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2901018147 | MI | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | D181470 | 01 | MI | BCBS | OTHER | 4525391 | 05 | MI | MEDICAID | 4379794 | 05 | MI | MEDICAID |