Basic Information
| Provider Information | |||||||||
| NPI: | 1003009903 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANLAECKEN | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.D.S. M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 5TH ST NE | ||||||||
| Address2: | P O BOX 1450 | ||||||||
| City: | WATERTOWN | ||||||||
| State: | SD | ||||||||
| PostalCode: | 572013712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058821500 | ||||||||
| FaxNumber: | 6058827090 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 4TH ST NE STE 103 | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | SD | ||||||||
| PostalCode: | 572011898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058821500 | ||||||||
| FaxNumber: | 6058827090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2007 | ||||||||
| LastUpdateDate: | 05/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | M817 | SD | Y | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.