Provider Demographics
NPI:1427074020
Name:VADNAL, DEREK (DMD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:VADNAL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12105 BRIDGETON SQ
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2616
Mailing Address - Country:US
Mailing Address - Phone:314-298-7772
Mailing Address - Fax:314-298-9895
Practice Address - Street 1:12105 BRIDGETON SQ
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2616
Practice Address - Country:US
Practice Address - Phone:314-298-7772
Practice Address - Fax:314-298-9895
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS603101223G0001X
MO20080085921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100095990CMedicaid