Provider Demographics
NPI:1972523678
Name:VAUGHAN, JOSEPH GATENS (DDS, INC)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:GATENS
Last Name:VAUGHAN
Suffix:
Gender:M
Credentials:DDS, INC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 CEDAR KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-8446
Mailing Address - Country:US
Mailing Address - Phone:304-645-2333
Mailing Address - Fax:
Practice Address - Street 1:130 CEDAR KNOLL DR
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-8446
Practice Address - Country:US
Practice Address - Phone:304-645-3333
Practice Address - Fax:304-647-5932
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV32681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0134332000Medicaid
WV000804538OtherBC/BS ID NUMBER
WV804538OtherUNITED CONCORDIA ID NUMBE