Provider Demographics
NPI:1710278619
Name:VANDER WILT, DAVID LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LEE
Last Name:VANDER WILT
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 1:3515 ALMA ST
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306-3539
Mailing Address - Country:US
Mailing Address - Phone:650-494-1900
Mailing Address - Fax:650-494-1902
Practice Address - Street 1:3515 ALMA ST
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306-3539
Practice Address - Country:US
Practice Address - Phone:650-494-1900
Practice Address - Fax:650-494-1902
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice