Basic Information
Provider Information
NPI: 1003009903
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: VANLAECKEN
FirstName: RYAN
MiddleName: K
NamePrefix: DR.
NameSuffix:  
Credential: D.D.S. M.S.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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: 25 5TH ST NE
Address2:  
City: WATERTOWN
State: SD
PostalCode: 572013712
CountryCode: US
TelephoneNumber: 6058821500
FaxNumber: 6058827090
Other Information
ProviderEnumerationDate: 08/23/2007
LastUpdateDate: 08/23/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223X0400XM817SDY Dental ProvidersDentistOrthodontics and Dentofacial Orthopedics

No ID Information.


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