Healthcare Provider Details

I. General information

NPI: 1639232457
Provider Name (Legal Business Name): DENTAL IMPRESSIONS, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1745 HOLTON RD SUITE C
MUSKEGON MI
49445-1453
US

IV. Provider business mailing address

1745 HOLTON RD SUITE C
MUSKEGON MI
49445-1453
US

V. Phone/Fax

Practice location:
  • Phone: 231-719-0033
  • Fax: 231-719-8933
Mailing address:
  • Phone: 231-719-0033
  • Fax: 231-719-8933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901018623
License Number StateMI

VIII. Authorized Official

Name: DR. MICHELLE L VANDYKE
Title or Position: SOLE PROPRIETOR
Credential: D.D.S.
Phone: 231-719-0033