Provider Demographics
NPI:1972578821
Name:VANDEWALLE, DENISE MARIE (DDS)
Entity type:Individual
Prefix:DR
First Name:DENISE
Middle Name:MARIE
Last Name:VANDEWALLE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-3028
Mailing Address - Country:US
Mailing Address - Phone:719-589-4771
Mailing Address - Fax:719-589-4258
Practice Address - Street 1:815 WEST AVE
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-3028
Practice Address - Country:US
Practice Address - Phone:719-589-4771
Practice Address - Fax:719-589-4258
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1053531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice