Provider Demographics
NPI:1194460162
Name:VANDERLEEST DENTAL LLC
Entity Type:Organization
Organization Name:VANDERLEEST DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:J
Authorized Official - Last Name:VANDERLEEST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-434-3950
Mailing Address - Street 1:2502 LINEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-7123
Mailing Address - Country:US
Mailing Address - Phone:920-434-3950
Mailing Address - Fax:
Practice Address - Street 1:2502 LINEVILLE RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-7123
Practice Address - Country:US
Practice Address - Phone:920-434-3950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty