Provider Demographics
NPI:1396841797
Name:VANREGENMORTER, JONPAUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONPAUL
Middle Name:
Last Name:VANREGENMORTER
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 1:25 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:TIVERTON
Mailing Address - State:RI
Mailing Address - Zip Code:02878-4409
Mailing Address - Country:US
Mailing Address - Phone:401-624-6119
Mailing Address - Fax:401-624-9233
Practice Address - Street 1:1359 MAIN RD
Practice Address - Street 2:
Practice Address - City:TIVERTON
Practice Address - State:RI
Practice Address - Zip Code:02878-4426
Practice Address - Country:US
Practice Address - Phone:401-624-9177
Practice Address - Fax:401-624-9233
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN027481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI80945OtherBLUE CROSS BLUE SHIELD
MAX12325OtherBLUE COSS BLUE SHIELD
MA0281077Medicare ID - Type UnspecifiedMASSHEALTH