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General NPI Number Information
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NPI Number | 1548659550
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Entity Type | Individual
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Provider Name | MITCHELL SCOTT VANDER BAAN D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 01/14/2015
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Last Update Date | 04/01/2025
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Provider Practice Location Address
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Address Line | 3300 GRAND RIDGE DR NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49525-7062
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Country | US
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Telephone | 616-364-6490
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Fax |
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Provider Business Mailing Address
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Address Line | 1001 BRENTWOOD CT
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City | COLUMBIA
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State | SC
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Zip | 29206-2871
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Country | US
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Telephone | 616-446-3974
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2901021199
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License Number State | MI
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