Provider Demographics
NPI:1477787489
Name:VANTUBERGEN, ELIZABETH ANNE (DDS)
Entity Type:Individual
Prefix:MISS
First Name:ELIZABETH
Middle Name:ANNE
Last Name:VANTUBERGEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21800 PONTIAC TRAIL
Mailing Address - Street 2:STE 100
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178
Mailing Address - Country:US
Mailing Address - Phone:248-437-8300
Mailing Address - Fax:248-437-8066
Practice Address - Street 1:21800 PONTIAC TRAIL
Practice Address - Street 2:STE 100
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178
Practice Address - Country:US
Practice Address - Phone:248-437-8300
Practice Address - Fax:248-437-8066
Is Sole Proprietor?:No
Enumeration Date:2009-05-05
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist