Healthcare Provider Details

I. General information

NPI: 1720275167
Provider Name (Legal Business Name): VANDERLUGT DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 10/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2008 EASTCASTLE DR SE STE C
GRAND RAPIDS MI
49508-8874
US

IV. Provider business mailing address

2008 EASTCASTLE DR SE STE C
GRAND RAPIDS MI
49508-8874
US

V. Phone/Fax

Practice location:
  • Phone: 616-455-8400
  • Fax: 616-455-4283
Mailing address:
  • Phone: 616-455-8400
  • Fax: 616-455-4283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberL732419
License Number StateMI

VIII. Authorized Official

Name: DAVID F VANDERLUGT
Title or Position: DDS
Credential:
Phone: 616-455-8400