MEDICARE: VANDERLUGT DENTAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	L732419	MI

General Provider Information

NPI Number	:	1720275167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VANDERLUGT DENTAL

Provider Business Mailing Address
First Line	:	2008 EASTCASTLE DR SE STE C
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-8874
Country	:	US
Telephone Number	:	616-455-8400
Fax Number	:	616-455-4283

Provider Business Practice Location Address
First Line	:	2008 EASTCASTLE DR SE STE C
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-8874
Country	:	US
Telephone Number	:	616-455-8400
Fax Number	:	616-455-4283

Authorized Official
Title or Position	:	DDS
Name	:	DAVID F VANDERLUGT
Credential	:
Telephone Number	:	616-455-8400

Provider Enumeration Date	:	10/01/2007
Last Update Date	:	10/01/2007

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