Healthcare Provider Details

I. General information

NPI: 1881615383
Provider Name (Legal Business Name): JOHN VAN TIEM D.D.S. P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E MAIN ST
STOCKBRIDGE MI
49285-9482
US

IV. Provider business mailing address

120 E MAIN ST PO BOX 93
STOCKBRIDGE MI
49285-9482
US

V. Phone/Fax

Practice location:
  • Phone: 517-851-8455
  • Fax: 517-851-8455
Mailing address:
  • Phone: 517-851-8455
  • Fax: 517-851-8455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901011876
License Number StateMI

VIII. Authorized Official

Name: DR. JOHN PAUL VAN TIEM
Title or Position: PRESIDENT
Credential: D.D.S
Phone: 517-851-8455