Provider Demographics
NPI:1720257421
Name:VANDERKOLK, BENEDICT (DDS)
Entity Type:Individual
Prefix:DR
First Name:BENEDICT
Middle Name:
Last Name:VANDERKOLK
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 1:1000 S OLD WOODWARD AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6723
Mailing Address - Country:US
Mailing Address - Phone:248-645-1060
Mailing Address - Fax:248-833-0126
Practice Address - Street 1:1000 S OLD WOODWARD AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6723
Practice Address - Country:US
Practice Address - Phone:248-645-1060
Practice Address - Fax:248-833-0126
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901010265122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist