MEDICARE: JAY C VANDEREST DDS

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	1223G0001X	General Practice Dentistry	2901014473	MI

General Provider Information

NPI Number	:	1164672044
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAY C VANDEREST DDS

Provider Business Mailing Address
First Line	:	106 S. MAIN ST
Second Line	:
City	:	ALMONT
State	:	MI
Zip	:	48003
Country	:	US
Telephone Number	:	810-798-3941
Fax Number	:	810-798-3141

Provider Business Practice Location Address
First Line	:	106 S MAIN ST
Second Line	:
City	:	ALMONT
State	:	MI
Zip	:	48003-1066
Country	:	US
Telephone Number	:	810-798-3941
Fax Number	:	810-798-3141

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JAY C VANDEREST
Credential	:	DDS
Telephone Number	:	810-798-3941

Provider Enumeration Date	:	09/26/2008
Last Update Date	:	10/20/2008

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