Healthcare Provider Details

I. General information

NPI: 1295867992
Provider Name (Legal Business Name): DAVID JOHN VANDERBOOM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1146 MEMORIAL DR
CHICOPEE MA
01020-3960
US

IV. Provider business mailing address

46 REPUBLIC DR
BLOOMFIELD CT
06002-5455
US

V. Phone/Fax

Practice location:
  • Phone: 413-593-8904
  • Fax: 413-593-5366
Mailing address:
  • Phone: 617-471-0223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number21684
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: