# LAKEHSORE OTOLARYNGOLOGY

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1770696379
- **Authorized official:** THEODORE S VANDERVEEN M.D. (PRESIDENT)
- **Authorized official phone:** (616) 393-2190

## Contact information

- **Practice address:** 577 MICHIGAN AVENUE, SUITE 101, HOLLAND, MI 49423
- **Practice address phone:** (616) 393-2190
- **Practice address fax:** (616) 393-0147
- **Mailing address:** 577 MICHIGAN AVENUE, SUITE 101, HOLLAND, MI 49423
- **Mailing address phone:** (616) 393-2190
- **Mailing address fax:** (616) 393-0147

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207YS0123X | Facial Plastic Surgery Physician | — | NULL | Yes |
| 207YS0123X | Facial Plastic Surgery Physician | — | — | Yes |

## Other

- **Enumeration date:** 08/16/2006
- **Last updated:** 08/22/2020