Provider Demographics
NPI:1659485464
Name:VANDERMEULEN, DAN J (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:DAN
Middle Name:J
Last Name:VANDERMEULEN
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 FAIRVIEW
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49083
Mailing Address - Country:US
Mailing Address - Phone:269-629-9465
Mailing Address - Fax:
Practice Address - Street 1:8191 MOORSBRIDGE ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024
Practice Address - Country:US
Practice Address - Phone:269-323-1022
Practice Address - Fax:269-323-0702
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101991223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1953960010OtherBCBS OF MI FOR MED CLAIMS