Healthcare Provider Details

I. General information

NPI: 1992794804
Provider Name (Legal Business Name): RICHARD ALAN VANDERWEELE D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 10/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5955 ZEAMER AVE 3RD DS/SGD
ELMENDORF AFB AK
99506-3702
US

IV. Provider business mailing address

5955 ZEAMER AVE 3RD DS/SGD
ELMENDORF AFB AK
99506-3702
US

V. Phone/Fax

Practice location:
  • Phone: 907-580-2973
  • Fax: 907-580-5022
Mailing address:
  • Phone: 907-580-2973
  • Fax: 907-580-5022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDS-029913-L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: