Provider Demographics
NPI:1659448264
Name:VANDUSEN, SCOTTY N (DDS)
Entity Type:Individual
Prefix:DR
First Name:SCOTTY
Middle Name:N
Last Name:VANDUSEN
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 1:2795 SKYLINE CT
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-3908
Mailing Address - Country:US
Mailing Address - Phone:970-242-3545
Mailing Address - Fax:970-254-9849
Practice Address - Street 1:2795 SKYLINE CT
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-3908
Practice Address - Country:US
Practice Address - Phone:970-242-3545
Practice Address - Fax:970-254-9849
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
CO100986122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO43604561Medicaid