Provider Demographics
NPI:1083003222
Name:VAN DE VYVER DENTAL, P.C.
Entity Type:Organization
Organization Name:VAN DE VYVER DENTAL, P.C.
Other - Org Name:GREAT LAKES DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DE VYVER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-320-8939
Mailing Address - Street 1:53620 VAN DYKE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-1831
Mailing Address - Country:US
Mailing Address - Phone:586-677-2828
Mailing Address - Fax:
Practice Address - Street 1:53620 VAN DYKE AVE STE 2
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-1831
Practice Address - Country:US
Practice Address - Phone:586-677-2828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-12
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010197021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty