Provider Demographics
NPI:1639232457
Name:DENTAL IMPRESSIONS, PLC
Entity Type:Organization
Organization Name:DENTAL IMPRESSIONS, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:VANDYKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:231-719-0033
Mailing Address - Street 1:1745 HOLTON RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-1453
Mailing Address - Country:US
Mailing Address - Phone:231-719-0033
Mailing Address - Fax:231-719-8933
Practice Address - Street 1:1745 HOLTON RD
Practice Address - Street 2:SUITE C
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-1453
Practice Address - Country:US
Practice Address - Phone:231-719-0033
Practice Address - Fax:231-719-8933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010186231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty