Provider Demographics
NPI:1962694737
Name:VANDERWALL, CLAY GORDON (DDS)
Entity type:Individual
Prefix:
First Name:CLAY
Middle Name:GORDON
Last Name:VANDERWALL
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 1:406 W BOUGHTON RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1340
Mailing Address - Country:US
Mailing Address - Phone:630-759-8940
Mailing Address - Fax:630-759-9392
Practice Address - Street 1:406 W BOUGHTON RD
Practice Address - Street 2:SUITE B
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1340
Practice Address - Country:US
Practice Address - Phone:630-759-8940
Practice Address - Fax:630-759-9392
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics