Healthcare Provider Details

I. General information

NPI: 1164672044
Provider Name (Legal Business Name): JAY C VANDEREST DDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 10/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 S MAIN ST
ALMONT MI
48003-1066
US

IV. Provider business mailing address

106 S. MAIN ST
ALMONT MI
48003
US

V. Phone/Fax

Practice location:
  • Phone: 810-798-3941
  • Fax: 810-798-3141
Mailing address:
  • Phone: 810-798-3941
  • Fax: 810-798-3141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901014473
License Number StateMI

VIII. Authorized Official

Name: DR. JAY C VANDEREST
Title or Position: OWNER
Credential: DDS
Phone: 810-798-3941