Provider Demographics
NPI:1215428487
Name:VANDER HEYDEN, ELLEN C (DDS)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:C
Last Name:VANDER HEYDEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:C
Other - Last Name:KRUEGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:132 4TH ST S
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:MN
Mailing Address - Zip Code:55328-9182
Mailing Address - Country:US
Mailing Address - Phone:414-897-6943
Mailing Address - Fax:
Practice Address - Street 1:327 13TH ST S STE 100
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:MN
Practice Address - Zip Code:55328-4631
Practice Address - Country:US
Practice Address - Phone:763-972-2915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14025122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist