MEDICARE: L VAN AMEYEDE 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	10374	MI

General Provider Information

NPI Number	:	1740393719
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	L VAN AMEYEDE DDS PC

Provider Business Mailing Address
First Line	:	51745 VAN DYKE AVE
Second Line	:
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48316-4451
Country	:	US
Telephone Number	:	586-323-1600
Fax Number	:	586-323-1644

Provider Business Practice Location Address
First Line	:	51745 VAN DYKE AVE
Second Line	:
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48316-4451
Country	:	US
Telephone Number	:	586-323-1600
Fax Number	:	586-323-1644

Authorized Official
Title or Position	:	OWNER
Name	:	MR. LARRY VAN AMEYEDE
Credential	:
Telephone Number	:	586-323-1600

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	08/22/2020

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