Provider Demographics
NPI:1700018074
Name:VAN HOFWEGEN, NATHAN DOUGLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:DOUGLAS
Last Name:VAN HOFWEGEN
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 1:621 W CENTRE AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024
Mailing Address - Country:US
Mailing Address - Phone:269-343-5386
Mailing Address - Fax:269-343-0913
Practice Address - Street 1:621 W CENTRE AVENUE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024
Practice Address - Country:US
Practice Address - Phone:269-343-5386
Practice Address - Fax:269-343-0913
Is Sole Proprietor?:No
Enumeration Date:2009-08-19
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08659122300000X
MI2901021322122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist