Provider Demographics
NPI:1649780776
Name:VANHOOSE UPPER SANDUSKY DENTAL
Entity type:Organization
Organization Name:VANHOOSE UPPER SANDUSKY DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:VANHOOSE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-370-8590
Mailing Address - Street 1:646 N SANDUSKY AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:43351-1028
Mailing Address - Country:US
Mailing Address - Phone:419-294-2125
Mailing Address - Fax:
Practice Address - Street 1:646 N SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:UPPER SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:43351-1028
Practice Address - Country:US
Practice Address - Phone:419-294-2125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.024515261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental