Provider Demographics
NPI:1528430774
Name:CASE, CARRIE
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:CASE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 SHELDON BLVD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4262
Mailing Address - Country:US
Mailing Address - Phone:616-776-2363
Mailing Address - Fax:616-776-2367
Practice Address - Street 1:101 SHELDON BLVD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4262
Practice Address - Country:US
Practice Address - Phone:616-776-2363
Practice Address - Fax:616-776-2367
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902012027124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist