Provider Demographics
NPI:1073692661
Name:VANHOFWEGEN, GARY (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:VANHOFWEGEN
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 1:18 WEST 4TH ST
Mailing Address - Street 2:PO BOX 224
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301
Mailing Address - Country:US
Mailing Address - Phone:712-262-4751
Mailing Address - Fax:712-262-7278
Practice Address - Street 1:18 WEST 4TH ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301
Practice Address - Country:US
Practice Address - Phone:712-262-4751
Practice Address - Fax:712-262-7278
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA063431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS413707OtherBC/BS OF KS
PA869122OtherUNITED CONCORDIA
IA0150375Medicaid
TN3144570OtherBC/BS OF TN
IA17805OtherBC/BS OF IA
NJ06343OtherBC/BS OF NJ