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General NPI Number Information
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NPI Number | 1558633909
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Entity Type | Organization
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Legal Business Name | RIVERTOWN DENTAL EXCELLENCE
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Dates
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Enumeration Date | 02/01/2012
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Last Update Date | 02/01/2012
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Provider Practice Location Address
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Address Line | 4565 WILSON AVE SW SUITE 2A
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City | GRANDVILLE
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State | MI
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Zip | 49418-2371
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Country | US
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Telephone | 616-538-0770
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Fax | 616-538-0359
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Provider Business Mailing Address
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Address Line | 4565 WILSON AVE SW SUITE 2A
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City | GRANDVILLE
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State | MI
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Zip | 49418-2371
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Country | US
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Telephone | 616-538-0770
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Fax | 616-538-0359
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Authorized Official
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Title or Position | OWNER
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Name | DR. JARED M VAN ITTERSUM
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Credential | D.D.S.
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Telephone | 616-538-0770
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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 | 2901019772
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License Number State | MI
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