Provider Demographics
NPI:1689780736
Name:VANDEWATER, JAMES EDWARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:EDWARD
Last Name:VANDEWATER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:
Other - Last Name:VANDEWATER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:164 CLARKSON EXECUTIVE PARK
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2114
Mailing Address - Country:US
Mailing Address - Phone:636-394-7330
Mailing Address - Fax:636-394-7908
Practice Address - Street 1:164 CLARKSON EXECUTIVE PARK
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011
Practice Address - Country:US
Practice Address - Phone:636-394-7330
Practice Address - Fax:363-394-7908
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO015342122300000X
IL019020310122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist