Provider Demographics
NPI:1518956713
Name:VANDERBERG, MICHAEL JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:VANDERBERG
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 1:813 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SHELDON
Mailing Address - State:IA
Mailing Address - Zip Code:51201-1546
Mailing Address - Country:US
Mailing Address - Phone:712-324-3124
Mailing Address - Fax:712-324-7268
Practice Address - Street 1:813 3RD AVE
Practice Address - Street 2:
Practice Address - City:SHELDON
Practice Address - State:IA
Practice Address - Zip Code:51201-1546
Practice Address - Country:US
Practice Address - Phone:712-324-3124
Practice Address - Fax:712-324-7268
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06085122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0098186Medicaid