Healthcare Provider Details

I. General information

NPI: 1720270366
Provider Name (Legal Business Name): MICHELLE VREDENBURG D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2007
Last Update Date: 08/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 HURON BLVD
MARYSVILLE MI
48040-1427
US

IV. Provider business mailing address

650 HURON BLVD
MARYSVILLE MI
48040-1427
US

V. Phone/Fax

Practice location:
  • Phone: 810-364-9060
  • Fax: 810-364-9117
Mailing address:
  • Phone: 810-364-9060
  • Fax: 810-364-9117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number015455
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: