Provider Demographics
NPI:1548309644
Name:VAN DE VYVER, SHAWN THOMAS (DDS)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:THOMAS
Last Name:VAN DE VYVER
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 1:73501 WINDMILL DR
Mailing Address - Street 2:
Mailing Address - City:BRUCE TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48065-3159
Mailing Address - Country:US
Mailing Address - Phone:734-320-8939
Mailing Address - Fax:
Practice Address - Street 1:53620 VAN DYKE AVE STE 2
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-1831
Practice Address - Country:US
Practice Address - Phone:586-677-2828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22687122300000X
MI29010197021223D0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health