Provider Demographics
NPI:1679593370
Name:VANDER HEIDE, KEVIN A (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:A
Last Name:VANDER HEIDE
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 1:9809 CHERRY VALLEY AVE SE
Mailing Address - Street 2:SUITE G
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-9592
Mailing Address - Country:US
Mailing Address - Phone:616-891-4424
Mailing Address - Fax:616-891-1398
Practice Address - Street 1:9809 CHERRY VALLEY AVE SE
Practice Address - Street 2:SUITE G
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-9592
Practice Address - Country:US
Practice Address - Phone:616-891-4424
Practice Address - Fax:616-891-1398
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010181911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice