Provider Demographics
NPI:1427303932
Name:KOVALAK, CAITLIN
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:
Last Name:KOVALAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAITLIN
Other - Middle Name:
Other - Last Name:BARON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:156 E CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464
Mailing Address - Country:US
Mailing Address - Phone:616-772-9898
Mailing Address - Fax:
Practice Address - Street 1:538 BOND AVE NW APT 814
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-6709
Practice Address - Country:US
Practice Address - Phone:517-610-1084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-20
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010206581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice