Provider Demographics
NPI:1164259115
Name:BULTEMA, ANGELA L (RDH)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:L
Last Name:BULTEMA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 CHERRY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4748
Mailing Address - Country:US
Mailing Address - Phone:616-235-7272
Mailing Address - Fax:
Practice Address - Street 1:669 STOCKING AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-5176
Practice Address - Country:US
Practice Address - Phone:616-235-1480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902012749124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist