Provider Demographics
NPI:1104008515
Name:DE GUZMAN, VAUGHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:VAUGHN
Middle Name:
Last Name:DE GUZMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5640 CLAYTON CIR
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-9503
Mailing Address - Country:US
Mailing Address - Phone:815-623-7366
Mailing Address - Fax:815-623-7331
Practice Address - Street 1:5640 CLAYTON CIR
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-9503
Practice Address - Country:US
Practice Address - Phone:815-623-7366
Practice Address - Fax:815-623-7331
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190258671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice