Provider Demographics
NPI:1013007491
Name:VANDEVENTER, JEFF (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFF
Middle Name:
Last Name:VANDEVENTER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3105 MIDDLE ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-4472
Mailing Address - Country:US
Mailing Address - Phone:812-379-4321
Mailing Address - Fax:812-379-1977
Practice Address - Street 1:3105 MIDDLE ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-4472
Practice Address - Country:US
Practice Address - Phone:812-379-4321
Practice Address - Fax:812-379-1977
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN118141223G0001X
IN120091541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200450770-AMedicaid