Provider Demographics
NPI:1598832040
Name:VANDEMARK, LORESE GERLONE GOMES (DDS)
Entity Type:Individual
Prefix:
First Name:LORESE
Middle Name:GERLONE GOMES
Last Name:VANDEMARK
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 1:3340 TULLY ROAD
Mailing Address - Street 2:STE D 6
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350
Mailing Address - Country:US
Mailing Address - Phone:209-526-0913
Mailing Address - Fax:209-526-6038
Practice Address - Street 1:3340 TULLY ROAD
Practice Address - Street 2:STE D 6
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350
Practice Address - Country:US
Practice Address - Phone:209-526-0913
Practice Address - Fax:209-526-6038
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43568122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist