Provider Demographics
NPI:1770788838
Name:VANDER BAAN, REBECCA ANNE
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:ANNE
Last Name:VANDER BAAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E LONG LAKE RD
Mailing Address - Street 2:STE 311
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304
Mailing Address - Country:US
Mailing Address - Phone:248-203-1119
Mailing Address - Fax:248-723-0052
Practice Address - Street 1:6161 ORCHARD LAKE
Practice Address - Street 2:STE 201 GREAT EXPRESSIONS DENTAL CENTERS
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322
Practice Address - Country:US
Practice Address - Phone:248-851-4915
Practice Address - Fax:248-851-5466
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019617122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist