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General NPI Number Information
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NPI Number | 1548309644
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Entity Type | Individual
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Provider Name | SHAWN THOMAS VAN DE VYVER DDS
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Gender | Male
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Dates
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Enumeration Date | 02/05/2007
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Last Update Date | 01/25/2022
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Provider Practice Location Address
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Address Line | 53620 VAN DYKE AVE STE 2
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City | SHELBY TOWNSHIP
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State | MI
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Zip | 48316-1831
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Country | US
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Telephone | 586-677-2828
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Fax |
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Provider Business Mailing Address
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Address Line | 73501 WINDMILL DR
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City | BRUCE TWP
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State | MI
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Zip | 48065-3159
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Country | US
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Telephone | 734-320-8939
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 22687
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 1223D0001X
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Taxonomy Name | Public Health Dentistry
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License Number | 2901019702
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2901019702
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License Number State | MI
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