Provider Demographics
NPI:1326239351
Name:VANDER WEIDE, JOSHUA G (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:G
Last Name:VANDER WEIDE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7336 PINE AIRE CT SW
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-7749
Mailing Address - Country:US
Mailing Address - Phone:616-485-7930
Mailing Address - Fax:
Practice Address - Street 1:20055 CARLYSLE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3803
Practice Address - Country:US
Practice Address - Phone:313-565-1102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010196921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice