Provider Demographics
NPI:1679592489
Name:VAN AMEYDE, LARRY (DDS)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:
Last Name:VAN AMEYDE
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 1:51745 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-4451
Mailing Address - Country:US
Mailing Address - Phone:586-323-1600
Mailing Address - Fax:586-323-1644
Practice Address - Street 1:51745 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-4451
Practice Address - Country:US
Practice Address - Phone:586-323-1600
Practice Address - Fax:586-323-1644
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103741223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9755011140OtherBLUE CROSS BLUE SHIELD ID
MIOP25120Medicare ID - Type Unspecified