Provider Demographics
NPI:1700064847
Name:L VAN AMEYDE DDS, PC
Entity Type:Organization
Organization Name:L VAN AMEYDE DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN AMEYDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-323-1600
Mailing Address - Street 1:51745 VAN DYKE
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48316
Mailing Address - Country:US
Mailing Address - Phone:586-323-1600
Mailing Address - Fax:586-323-1644
Practice Address - Street 1:51745 VAN DYKE
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48316
Practice Address - Country:US
Practice Address - Phone:586-323-1600
Practice Address - Fax:586-323-1644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103741223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9755011140OtherBCBS ID #
MIOP25120Medicare PIN