Provider Demographics
NPI:1649319161
Name:VANDRAGT, ROBERT BRUCE (DENTIST)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BRUCE
Last Name:VANDRAGT
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 MUNSON AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3060
Mailing Address - Country:US
Mailing Address - Phone:231-946-2160
Mailing Address - Fax:231-946-2161
Practice Address - Street 1:431 MUNSON AVE
Practice Address - Street 2:SUITE F
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3060
Practice Address - Country:US
Practice Address - Phone:231-946-2160
Practice Address - Fax:231-946-2161
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010113571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4040757Medicaid