Healthcare Provider Details

I. General information

NPI: 1740251073
Provider Name (Legal Business Name): VAN DERHEI IMPLANT PROSTHETICS DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 BRASELTON HWY #102
DACULA GA
30019
US

IV. Provider business mailing address

3625 BRASELTON HWY #102
DACULA GA
30019
US

V. Phone/Fax

Practice location:
  • Phone: 678-318-3353
  • Fax: 678-318-3350
Mailing address:
  • Phone: 678-318-3353
  • Fax: 678-318-3350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN011854
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDN012702
License Number StateGA

VIII. Authorized Official

Name: DR. PATRICK VAN DERHEI
Title or Position: CO OWNER
Credential: DDS MSD
Phone: 678-318-3353