NPIMap

Organization Active NPI

Modern Periodontics

  • Periodontics
  • Grand Rapids, MI
National Provider Identifier
1679855761
Registry record updated Sep 14, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
PeriodonticsTaxonomy code 1223P0300X
License
16791 Issued in MI
Legal business name
MODERN PERIODONTICS
Practice address
2356 32ND Street
Suite #100
Grand Rapids, MI 49508-1510
Phone
(616) 241-5658
NPI assigned
Sep 14, 2011
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 14, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Erin Nicole Moerdyke
Title
Office Manager
Phone
(616) 241-5658

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
PeriodonticsGroup: 193400000X SINGLE SPECIALTY GROUP 1223P0300X 16791 MI Primary

Addresses

Primary practice location

2356 32ND Street
Suite #100
Grand Rapids, MI 49508-1510

Mailing address

2356 32ND Street
Suite #100
Grand Rapids, MI 49508
Phone (616) 241-5658

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1315958400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1315958400000",
    "number": "1679855761",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2356 32ND STREET",
            "address_2": "SUITE #100",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "49508",
            "telephone_number": "616-241-5658"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2356 32ND STREET",
            "address_2": "SUITE #100",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495081510",
            "telephone_number": "616-241-5658"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MODERN PERIODONTICS",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-09-14",
        "last_updated": "2011-09-14",
        "status": "A",
        "authorized_official_last_name": "MOERDYKE",
        "authorized_official_first_name": "ERIN",
        "authorized_official_middle_name": "NICOLE",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "616-241-5658",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "1223P0300X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Periodontics",
            "state": "MI",
            "license": "16791",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Grand Rapids, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 14, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.