Provider Demographics
NPI:1649254707
Name:VAN WIEREN, CLARE ROYCE (DDS)
Entity type:Individual
Prefix:DR
First Name:CLARE
Middle Name:ROYCE
Last Name:VAN WIEREN
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 1:601 MICHIGAN AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4951
Mailing Address - Country:US
Mailing Address - Phone:616-392-5573
Mailing Address - Fax:616-392-9610
Practice Address - Street 1:601 MICHIGAN AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4951
Practice Address - Country:US
Practice Address - Phone:616-392-5573
Practice Address - Fax:616-392-9610
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010098021223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4062988Medicaid
MI2980529Medicaid
MI9757063760OtherBCBS MEDICAL NUMBER
MID098020OtherBCBS DENTAL NUMBER
MI9757063760OtherBCBS MEDICAL NUMBER