Provider Demographics
NPI:1710281795
Name:VAN DERHEI IMPLANT AND PROSTHETICS
Entity Type:Organization
Organization Name:VAN DERHEI IMPLANT AND PROSTHETICS
Other - Org Name:VIP FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DERHEI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:678-318-3353
Mailing Address - Street 1:3590 BRASELTON HWY
Mailing Address - Street 2:STE 103
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-1117
Mailing Address - Country:US
Mailing Address - Phone:678-318-3353
Mailing Address - Fax:678-318-3350
Practice Address - Street 1:3590 BRASELTON HWY
Practice Address - Street 2:STE 103
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-1117
Practice Address - Country:US
Practice Address - Phone:678-318-3353
Practice Address - Fax:678-318-3350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012702261QD0000X
GADN011854261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental