Provider Demographics
NPI:1912038258
Name:VANDEVENTER, JON TYLER (DDS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:TYLER
Last Name:VANDEVENTER
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 1:8099 ROSE HILL DR
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-2384
Mailing Address - Country:US
Mailing Address - Phone:812-853-2961
Mailing Address - Fax:
Practice Address - Street 1:8099 ROSE HILL DR
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-2384
Practice Address - Country:US
Practice Address - Phone:812-853-2961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010766A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist