Active NPI
Brent A Medema, D.D.S.
- Endodontics
- Caledonia, MI
National Provider Identifier
1043628670
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Endodontics
- License
- 2901021310
- Practice address
- 9021 N Rodgers CT SE
Suite E
Caledonia, MI 49316-7649 - Phone
- (616) 891-1400
- NPI assigned
- Jul 28, 2014
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Endodontics | 1223E0200X | 2901021310 | MI | Primary |
Addresses
Primary practice location
9021 N Rodgers CT SE
Suite E
Caledonia, MI 49316-7649
Mailing address
7090 Hickory Point Dr
Portage, MI 49024-4039
Phone (269) 760-5505
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MI
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20151111000294 | MI | Order and Referring Only - Other (Physician) | 4688984248 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2901021310 | MI | MD | Endodontist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1406505600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1406505600000",
"number": "1043628670",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "7090 HICKORY POINT DR",
"city": "PORTAGE",
"state": "MI",
"postal_code": "490244039",
"telephone_number": "269-760-5505"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "9021 N RODGERS CT SE",
"address_2": "SUITE E",
"city": "CALEDONIA",
"state": "MI",
"postal_code": "493167649",
"telephone_number": "616-891-1400"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MEDEMA",
"first_name": "BRENT",
"middle_name": "A",
"name_prefix": "Dr.",
"credential": "D.D.S.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2014-07-28",
"last_updated": "2014-07-28",
"status": "A"
},
"taxonomies": [
{
"code": "1223E0200X",
"taxonomy_group": "",
"desc": "Dentist, Endodontics",
"state": "MI",
"license": "2901021310",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Caledonia, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 28, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.