Provider Demographics
NPI:1740251073
Name:VAN DERHEI IMPLANT PROSTHETICS DENTAL LLC
Entity type:Organization
Organization Name:VAN DERHEI IMPLANT PROSTHETICS DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DERHEI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MSD
Authorized Official - Phone:678-318-3353
Mailing Address - Street 1:3625 BRASELTON HWY
Mailing Address - Street 2:#102
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019
Mailing Address - Country:US
Mailing Address - Phone:678-318-3353
Mailing Address - Fax:678-318-3350
Practice Address - Street 1:3625 BRASELTON HWY
Practice Address - Street 2:#102
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019
Practice Address - Country:US
Practice Address - Phone:678-318-3353
Practice Address - Fax:678-318-3350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0118541223G0001X
GADN0127021223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty