Provider Demographics
NPI:1871982140
Name:VANGENDEREN, GARRY (DDS)
Entity type:Individual
Prefix:DR
First Name:GARRY
Middle Name:
Last Name:VANGENDEREN
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 1:330 THE VILLAGE DRIVE
Mailing Address - Street 2:APT 112
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277
Mailing Address - Country:US
Mailing Address - Phone:201-214-3838
Mailing Address - Fax:
Practice Address - Street 1:17 W 4TH ST
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-3636
Practice Address - Country:US
Practice Address - Phone:719-383-2083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-09
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002024131223G0001X
CADDS1085831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice