MEDICARE: DR. MARTIN D VREDENBURG D.D.S.

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	2901016925	MI

General Provider Information

NPI Number	:	1962482653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARTIN D VREDENBURG D.D.S.

Provider Business Mailing Address
First Line	:	1150 N HUDSON ST
Second Line	:	P.O.BOX 146
City	:	LOWELL
State	:	MI
Zip	:	49331-1000
Country	:	US
Telephone Number	:	616-897-8429
Fax Number	:	616-897-2197

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	:	616-897-2197

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

Provider Enumeration Date	:	01/19/2006
Last Update Date	:	07/08/2007

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