Provider Demographics
NPI:1295867992
Name:VANDERBOOM, DAVID JOHN (DMD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JOHN
Last Name:VANDERBOOM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 REPUBLIC DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-5455
Mailing Address - Country:US
Mailing Address - Phone:617-471-0223
Mailing Address - Fax:
Practice Address - Street 1:1146 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:CHICOPEE
Practice Address - State:MA
Practice Address - Zip Code:01020-3960
Practice Address - Country:US
Practice Address - Phone:413-593-8904
Practice Address - Fax:413-593-5366
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice