Basic Information
| Provider Information | |||||||||
| NPI: | 1659448264 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDUSEN | ||||||||
| FirstName: | SCOTTY | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2795 SKYLINE CT | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815063908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702423545 | ||||||||
| FaxNumber: | 9702549849 | ||||||||
| Practice Location | |||||||||
| Address1: | 2795 SKYLINE CT | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815063908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702423545 | ||||||||
| FaxNumber: | 9702549849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 100986 | CO | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 43604561 | 05 | CO | MEDICAID |