Provider Demographics
NPI:1982836714
Name:DELLAVECCHIA DENTAL SERVICES, P.C.
Entity Type:Organization
Organization Name:DELLAVECCHIA DENTAL SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:DELLAVECCHIA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:269-857-1431
Mailing Address - Street 1:430 130TH AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:MI
Mailing Address - Zip Code:49406-5100
Mailing Address - Country:US
Mailing Address - Phone:269-857-1431
Mailing Address - Fax:269-857-4089
Practice Address - Street 1:430 130TH AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:MI
Practice Address - Zip Code:49406-5100
Practice Address - Country:US
Practice Address - Phone:269-857-1431
Practice Address - Fax:269-857-4089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-12
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901018649261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental