Healthcare Provider Details

I. General information

NPI: 1932223591
Provider Name (Legal Business Name): JAN CORNELIS VANDEREST DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 11/17/2016
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

PO BOX 425 106 SOUTH MAIN ST
ALMONT MI
48003-0425
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:
Title or Position:
Credential:
Phone: