Healthcare Provider Details

I. General information

NPI: 1295862340
Provider Name (Legal Business Name): MICHAEL H. VANDERVEEN DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865 CLYDE PARK AVE SW
WYOMING MI
49509-2911
US

IV. Provider business mailing address

2865 CLYDE PARK AVE SW
WYOMING MI
49509-2911
US

V. Phone/Fax

Practice location:
  • Phone: 616-940-0940
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number18692
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11356
License Number StateMI

VIII. Authorized Official

Name: DR. MICHAEL H VANDERVEEN
Title or Position: OWNER
Credential: D.D.S.
Phone: 616-940-0940