Provider Demographics
NPI:1982796447
Name:MULDER, KENNETH J (DDS,MS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:MULDER
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2144 E PARIS AVE SE STE 150
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6126
Mailing Address - Country:US
Mailing Address - Phone:616-942-2000
Mailing Address - Fax:
Practice Address - Street 1:2144 E PARIS AVE SE STE 150
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6126
Practice Address - Country:US
Practice Address - Phone:616-942-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKM0114121223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D16069001Medicare ID - Type Unspecified