Provider Demographics
NPI:1922109370
Name:DUTCHMAN DENTAL LLC
Entity Type:Organization
Organization Name:DUTCHMAN DENTAL LLC
Other - Org Name:JON-PAUL VAN REGENMORTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JON-PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN REGENMORTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:401-624-9177
Mailing Address - Street 1:1359 MAIN RD
Mailing Address - Street 2:
Mailing Address - City:TIVERTON
Mailing Address - State:RI
Mailing Address - Zip Code:02878
Mailing Address - Country:US
Mailing Address - Phone:401-624-9177
Mailing Address - Fax:401-624-9233
Practice Address - Street 1:1359 MAIN RD
Practice Address - Street 2:
Practice Address - City:TIVERTON
Practice Address - State:RI
Practice Address - Zip Code:02878
Practice Address - Country:US
Practice Address - Phone:401-624-9177
Practice Address - Fax:401-624-9233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN27481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0281077Medicaid