Provider Demographics
NPI:1275735029
Name:DERKSEN, DANIEL J
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:J
Last Name:DERKSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 ABBOTT RD
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-3101
Mailing Address - Country:US
Mailing Address - Phone:517-337-0351
Mailing Address - Fax:517-337-5610
Practice Address - Street 1:714 ABBOTT RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-3101
Practice Address - Country:US
Practice Address - Phone:517-337-0351
Practice Address - Fax:517-337-5610
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010195851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice