MEDICARE: DR. ZACHARY RENE VANDEVOORDE DMD

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	122300000X	Dentist	12013011A	IN

General Provider Information

NPI Number	:	1871073775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ZACHARY RENE VANDEVOORDE DMD

Provider Business Mailing Address
First Line	:	556 N OAK DR
Second Line	:
City	:	PLYMOUTH
State	:	IN
Zip	:	46563-1664
Country	:	US
Telephone Number	:	574-936-3921
Fax Number	:	574-936-1010

Provider Business Practice Location Address
First Line	:	556 N OAK DR
Second Line	:
City	:	PLYMOUTH
State	:	IN
Zip	:	46563-1664
Country	:	US
Telephone Number	:	574-936-3921
Fax Number	:	574-936-1010

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2018
Last Update Date	:	08/20/2018

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