=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982626966
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KILLINGER & VANDER BEEK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2006
-----------------------------------------------------
Last Update Date | 04/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 998 CRESCENT LAKE RD
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48327-2594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-682-9653
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 998 CRESCENT LAKE RD
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48327-2594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-682-9653
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | MICHAEL VANDER BEEK
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 248-682-9653
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 01367
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------