Provider Demographics
NPI:1790364990
Name:DEHAAN, MAX
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:
Last Name:DEHAAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 E 28TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-3123
Mailing Address - Country:US
Mailing Address - Phone:605-553-1108
Mailing Address - Fax:
Practice Address - Street 1:4201 SAINT ANTOINE ST # UHC
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:605-553-1108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty