Healthcare Provider Details

I. General information

NPI: 1912360553
Provider Name (Legal Business Name): MATTHEW DAVID VANHOOF DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 07/15/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 MDG UNIT 3215 RAMSTEIN AB
APO AE
09094-3215
US

IV. Provider business mailing address

86 MDG UNIT 3215 RAMSTEIN AB
APO AE
09094-3215
US

V. Phone/Fax

Practice location:
  • Phone: 313-479-2609
  • Fax:
Mailing address:
  • Phone: 313-479-2609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number1001323-15
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1001323
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: