Provider Demographics
NPI:1902877988
Name:DOEZEMA, C PHILIP (DDS)
Entity Type:Individual
Prefix:
First Name:C
Middle Name:PHILIP
Last Name:DOEZEMA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 BURTON SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4600
Mailing Address - Country:US
Mailing Address - Phone:616-243-7836
Mailing Address - Fax:616-243-7874
Practice Address - Street 1:2003 BURTON SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4600
Practice Address - Country:US
Practice Address - Phone:616-243-7836
Practice Address - Fax:616-243-7874
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010112283122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist