Provider Demographics
NPI:1932223591
Name:VANDEREST, JAN CORNELIS (DDS)
Entity Type:Individual
Prefix:MR
First Name:JAN
Middle Name:CORNELIS
Last Name:VANDEREST
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:PO BOX 425
Mailing Address - Street 2:106 SOUTH MAIN ST
Mailing Address - City:ALMONT
Mailing Address - State:MI
Mailing Address - Zip Code:48003-0425
Mailing Address - Country:US
Mailing Address - Phone:810-798-3941
Mailing Address - Fax:810-798-3141
Practice Address - Street 1:106 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ALMONT
Practice Address - State:MI
Practice Address - Zip Code:48003-1066
Practice Address - Country:US
Practice Address - Phone:810-798-3941
Practice Address - Fax:810-798-3141
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010144731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice