Provider Demographics
NPI:1588748198
Name:HIDDEMA, ROBERT J (DDS)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:HIDDEMA
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 1:555 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090
Mailing Address - Country:US
Mailing Address - Phone:269-323-2889
Mailing Address - Fax:269-639-1264
Practice Address - Street 1:555 BROADWAY
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090
Practice Address - Country:US
Practice Address - Phone:269-323-2889
Practice Address - Fax:269-639-1264
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901012500122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist