=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578202040
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GAIGE RYAN VANDEZANDE DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2022
-----------------------------------------------------
Last Update Date | 06/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 804 S 3RD ST
-----------------------------------------------------
City | ST CHARLES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60174-4053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-377-1200
-----------------------------------------------------
Fax | 630-377-9801
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2142 PRENTISS DR APT 112
-----------------------------------------------------
City | DOWNERS GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60516-2214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-245-2170
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019033650
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------