Basic Information
| Provider Information | |||||||||
| NPI: | 1558473686 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANBEUKERING | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 CRESTWOOD BLVD | ||||||||
| Address2: | STE 211 | ||||||||
| City: | IRONDALE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352102034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2052716851 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3700 BLUE SPRING RD NW STE F | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358103457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568529994 | ||||||||
| FaxNumber: | 2568527797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 03/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN013075 | GA | N | Dental Providers | Dentist | General Practice | 1223G0001X | 4985 | AL | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 306805203A | 05 | GA | MEDICAID | 009933948 | 05 | AL | MEDICAID | 009930105 | 05 | AL | MEDICAID |