Provider Demographics
NPI:1912172016
Name:DUTCHMEN DENTAL LLC
Entity Type:Organization
Organization Name:DUTCHMEN DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JON PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN REGENMORTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:401-624-9177
Mailing Address - Street 1:1359 MAIN RD
Mailing Address - Street 2:
Mailing Address - City:TIVERTON
Mailing Address - State:RI
Mailing Address - Zip Code:02878-4426
Mailing Address - Country:US
Mailing Address - Phone:401-624-9177
Mailing Address - Fax:401-624-9233
Practice Address - Street 1:1359 MAIN RD
Practice Address - Street 2:
Practice Address - City:TIVERTON
Practice Address - State:RI
Practice Address - Zip Code:02878-4426
Practice Address - Country:US
Practice Address - Phone:401-624-9177
Practice Address - Fax:401-624-9233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN027481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI8094-5OtherBLUE CROSS BLUE SHIELD OF RI
MAX12325OtherBLUE CROSS BLUE SHIELD OF MA
MA0281077Medicaid
MA9197544Medicaid