Provider Demographics
NPI:1720270366
Name:VREDENBURG, MICHELLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:VREDENBURG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 HURON BLVD
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48040-1427
Mailing Address - Country:US
Mailing Address - Phone:810-364-9060
Mailing Address - Fax:810-364-9117
Practice Address - Street 1:650 HURON BLVD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-1427
Practice Address - Country:US
Practice Address - Phone:810-364-9060
Practice Address - Fax:810-364-9117
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI015455122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist