Provider Demographics
NPI:1215299367
Name:VANDENBOSCH, KEVIN BENJAMIN (OD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:BENJAMIN
Last Name:VANDENBOSCH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4615 BREMER ST SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2239
Mailing Address - Country:US
Mailing Address - Phone:616-240-5632
Mailing Address - Fax:
Practice Address - Street 1:1116 W GANSON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-4240
Practice Address - Country:US
Practice Address - Phone:877-852-8463
Practice Address - Fax:517-782-5166
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004710152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist