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General NPI Number Information
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NPI Number | 1720275167
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Entity Type | Organization
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Legal Business Name | VANDERLUGT DENTAL
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Dates
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Enumeration Date | 10/01/2007
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Last Update Date | 10/01/2007
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Provider Practice Location Address
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Address Line | 2008 EASTCASTLE DR SE STE C
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City | GRAND RAPIDS
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State | MI
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Zip | 49508-8874
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Country | US
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Telephone | 616-455-8400
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Fax | 616-455-4283
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Provider Business Mailing Address
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Address Line | 2008 EASTCASTLE DR SE STE C
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City | GRAND RAPIDS
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State | MI
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Zip | 49508-8874
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Country | US
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Telephone | 616-455-8400
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Fax | 616-455-4283
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Authorized Official
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Title or Position | DDS
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Name | DAVID F VANDERLUGT
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Credential |
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Telephone | 616-455-8400
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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 | L732419
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License Number State | MI
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