Provider Demographics
NPI:1154098374
Name:MARTIN D VREDENBURG DDS PC
Entity Type:Organization
Organization Name:MARTIN D VREDENBURG DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:VREDENBURG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-897-8429
Mailing Address - Street 1:PO BOX 146
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49331-0146
Mailing Address - Country:US
Mailing Address - Phone:616-897-8429
Mailing Address - Fax:
Practice Address - Street 1:1150 N HUDSON ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-1000
Practice Address - Country:US
Practice Address - Phone:616-897-8429
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental