Provider Demographics
NPI:1841540168
Name:MATT VANDERMOLEN DDS PC
Entity type:Organization
Organization Name:MATT VANDERMOLEN DDS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:G
Authorized Official - Last Name:VANDERMOLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:217-546-3333
Mailing Address - Street 1:4701 WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-9694
Mailing Address - Country:US
Mailing Address - Phone:217-546-3333
Mailing Address - Fax:217-546-1110
Practice Address - Street 1:4701 WABASH AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-9694
Practice Address - Country:US
Practice Address - Phone:217-546-3333
Practice Address - Fax:217-546-1110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190197851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty