Provider Demographics
NPI:1841416856
Name:VANWALLEGHEM, PAUL S (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:S
Last Name:VANWALLEGHEM
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 1:50505 SCHOENHERR RD
Mailing Address - Street 2:STE 170
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-3140
Mailing Address - Country:US
Mailing Address - Phone:313-886-9201
Mailing Address - Fax:313-881-5068
Practice Address - Street 1:50505 SCHOENHERR RD
Practice Address - Street 2:STE 170
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-3140
Practice Address - Country:US
Practice Address - Phone:586-803-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID145251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice