Provider Demographics
NPI:1346873288
Name:VAN DE VYVER DENTAL, P.C.
Entity Type:Organization
Organization Name:VAN DE VYVER DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DE VYVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-320-8939
Mailing Address - Street 1:73501 WINDMILL DR
Mailing Address - Street 2:
Mailing Address - City:BRUCE TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48065-3159
Mailing Address - Country:US
Mailing Address - Phone:586-372-7045
Mailing Address - Fax:
Practice Address - Street 1:25810 KELLY RD STE 2
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4467
Practice Address - Country:US
Practice Address - Phone:734-320-8939
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental