Provider Demographics
NPI:1821537010
Name:MARSHALL FAMILY DENTISTRY PLLC
Entity Type:Organization
Organization Name:MARSHALL FAMILY DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:VANDERMEULEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:269-781-6300
Mailing Address - Street 1:207 WINSTON DR
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-8526
Mailing Address - Country:US
Mailing Address - Phone:269-781-6300
Mailing Address - Fax:269-781-8459
Practice Address - Street 1:207 WINSTON DR
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-8526
Practice Address - Country:US
Practice Address - Phone:269-781-6300
Practice Address - Fax:269-781-8459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI13841122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty