Healthcare Provider Details

I. General information

NPI: 1306070495
Provider Name (Legal Business Name): VREDENBURG-LESLIE DENTISTRY PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2009
Last Update Date: 05/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 N MAIN ST
LESLIE MI
49251-9426
US

IV. Provider business mailing address

126 N MAIN ST
LESLIE MI
49251-9426
US

V. Phone/Fax

Practice location:
  • Phone: 517-589-5400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901016925
License Number StateMI

VIII. Authorized Official

Name: DR. MARTIN VREDENBURG
Title or Position: PRESIDENT
Credential:
Phone: 517-589-5400