MEDICARE: MARTIN D VREDENBURG DDS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1154098374
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARTIN D VREDENBURG DDS PC

Provider Business Mailing Address
First Line	:	PO BOX 146
Second Line	:
City	:	LOWELL
State	:	MI
Zip	:	49331-0146
Country	:	US
Telephone Number	:	616-897-8429
Fax Number	:

Provider Business Practice Location Address
First Line	:	1150 N HUDSON ST
Second Line	:
City	:	LOWELL
State	:	MI
Zip	:	49331-1000
Country	:	US
Telephone Number	:	616-897-8429
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	MARTIN VREDENBURG
Credential	:	DDS
Telephone Number	:	616-897-8429

Provider Enumeration Date	:	08/25/2021
Last Update Date	:	08/25/2021

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