Provider Demographics
NPI:1962482653
Name:VREDENBURG, MARTIN D (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:D
Last Name:VREDENBURG
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 1:1150 N HUDSON ST
Mailing Address - Street 2:P.O.BOX 146
Mailing Address - City:LOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49331-1000
Mailing Address - Country:US
Mailing Address - Phone:616-897-8429
Mailing Address - Fax:616-897-2197
Practice Address - Street 1:1150 N HUDSON ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-1000
Practice Address - Country:US
Practice Address - Phone:616-897-8429
Practice Address - Fax:616-897-2197
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010169251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice