Healthcare Provider Details

I. General information

NPI: 1124836531
Provider Name (Legal Business Name): MATTAWAN FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2024
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56400 CITY CENTER CIR
MATTAWAN MI
49071-8380
US

IV. Provider business mailing address

56400 CITY CENTER CIR
MATTAWAN MI
49071-8380
US

V. Phone/Fax

Practice location:
  • Phone: 269-568-2609
  • Fax:
Mailing address:
  • Phone: 269-568-2609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: DR. JONATHAN VANDENBURGH
Title or Position: OWNER
Credential: DDS
Phone: 269-568-2609