Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 22687 | TX |
Y | 122300000X | Dentist | 2901019702 | MI |
N | 1223D0001X | Dental Public Health | 2901019702 | MI |
NPI | 1548309644 |
---|---|
Provider Name | Dr. Shawn Thomas Van De Vyver |
First Address | Bruce Twp, MI 48065-3159 |
Second Address | Shelby Township, MI 48316-1831 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/02/2007 |
Last Update Date | 25/01/2022 |