1689780736 NPI number — DR. JAMES EDWARD VANDEWATER DMD

Table of content: DR. JAMES EDWARD VANDEWATER DMD (NPI 1689780736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689780736 NPI number — DR. JAMES EDWARD VANDEWATER DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDEWATER
Provider First Name:
JAMES
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VANDEWATER
Provider Other First Name:
JAY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DMD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1689780736
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
164 CLARKSON EXECUTIVE PARK
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLISVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63011-2114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-394-7330
Provider Business Mailing Address Fax Number:
636-394-7908

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
164 CLARKSON EXECUTIVE PARK
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLISVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-394-7330
Provider Business Practice Location Address Fax Number:
363-394-7908
Provider Enumeration Date:
08/22/2006

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: 122300000X , with the licence number:  015342 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 122300000X , with the licence number: 019020310 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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