Provider Demographics
NPI:1023194487
Name:VANDERMOLEN, MATT GORDON (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATT
Middle Name:GORDON
Last Name:VANDERMOLEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-9694
Mailing Address - Country:US
Mailing Address - Phone:217-546-3333
Mailing Address - Fax:
Practice Address - Street 1:4701 WABASH AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-9694
Practice Address - Country:US
Practice Address - Phone:217-546-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice