1073692661 NPI number — DR. GARY VANHOFWEGEN DDS

Table of content: DR. GARY VANHOFWEGEN DDS (NPI 1073692661)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073692661 NPI number — DR. GARY VANHOFWEGEN DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANHOFWEGEN
Provider First Name:
GARY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073692661
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18 WEST 4TH ST
Provider Second Line Business Mailing Address:
PO BOX 224
Provider Business Mailing Address City Name:
SPENCER
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-262-4751
Provider Business Mailing Address Fax Number:
712-262-7278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18 WEST 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPENCER
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-262-4751
Provider Business Practice Location Address Fax Number:
712-262-7278
Provider Enumeration Date:
11/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  06343 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 413707 . This is a "BC/BS OF KS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 869122 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0150375 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3144570 . This is a "BC/BS OF TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 17805 . This is a "BC/BS OF IA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 06343 . This is a "BC/BS OF NJ" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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