Provider Demographics
NPI:1952523094
Name:VANDEVENTER, JAMES C (DDS)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:C
Last Name:VANDEVENTER
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 1:200 E MAIN ST
Mailing Address - Street 2:STE.3
Mailing Address - City:BLOOMFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:47424-2401
Mailing Address - Country:US
Mailing Address - Phone:812-384-3736
Mailing Address - Fax:
Practice Address - Street 1:200 E MAIN ST
Practice Address - Street 2:STE.3
Practice Address - City:BLOOMFIELD
Practice Address - State:IN
Practice Address - Zip Code:47424-2401
Practice Address - Country:US
Practice Address - Phone:812-384-3736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009153B1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice