Provider Demographics
NPI:1326530114
Name:JANDERNOA, NATHAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:
Last Name:JANDERNOA
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 1:2410 LAKE LANSING RD STE 2
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-3659
Mailing Address - Country:US
Mailing Address - Phone:517-371-5342
Mailing Address - Fax:517-371-5320
Practice Address - Street 1:2410 LAKE LANSING RD STE 2
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-3659
Practice Address - Country:US
Practice Address - Phone:517-371-5342
Practice Address - Fax:517-371-5320
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901022641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI365155275Medicaid