1932223591 NPI number — MR. JAN CORNELIS VANDEREST DDS

Table of content: MR. JAN CORNELIS VANDEREST DDS (NPI 1932223591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932223591 NPI number — MR. JAN CORNELIS VANDEREST DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDEREST
Provider First Name:
JAN
Provider Middle Name:
CORNELIS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932223591
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 425
Provider Second Line Business Mailing Address:
106 SOUTH MAIN ST
Provider Business Mailing Address City Name:
ALMONT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48003-0425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-798-3941
Provider Business Mailing Address Fax Number:
810-798-3141

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALMONT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48003-1066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-798-3941
Provider Business Practice Location Address Fax Number:
810-798-3141
Provider Enumeration Date:
03/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  2901014473 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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