Provider Demographics
NPI:1497914113
Name:VANITTERSUM, JARED MATTHEW (DDS)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:MATTHEW
Last Name:VANITTERSUM
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 1:1221 E SHERMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1811
Mailing Address - Country:US
Mailing Address - Phone:231-739-5105
Mailing Address - Fax:231-739-7432
Practice Address - Street 1:1221 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1811
Practice Address - Country:US
Practice Address - Phone:231-739-5105
Practice Address - Fax:231-739-7432
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019772122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist