Active NPI
Clay Gordon Vanderwall, DDS
- Orthodontics and Dentofacial Orthopedics Dentistry
- Bolingbrook, IL
National Provider Identifier
1962694737
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Orthodontics and Dentofacial Orthopedics Dentistry
- Practice address
- 406 W Boughton Rd
Suite B
Bolingbrook, IL 60440-1340 - Phone
- (630) 759-8940
- Fax
- (630) 759-9392
- NPI assigned
- Aug 15, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Orthodontics and Dentofacial Orthopedics Dentistry | 1223X0400X | IL | Primary |
Addresses
Primary practice location
406 W Boughton Rd
Suite B
Bolingbrook, IL 60440-1340
Mailing address
406 W Boughton Rd
Suite B
Bolingbrook, IL 60440-1340
Phone (630) 759-8940
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 019027465 | IL | MD | Orthodontics and Dentofacial Orthopedic Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1187136000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1187136000000",
"number": "1962694737",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "406 W BOUGHTON RD",
"address_2": "SUITE B",
"city": "BOLINGBROOK",
"state": "IL",
"postal_code": "604401340",
"telephone_number": "630-759-8940",
"fax_number": "630-759-9392"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "406 W BOUGHTON RD",
"address_2": "SUITE B",
"city": "BOLINGBROOK",
"state": "IL",
"postal_code": "604401340",
"telephone_number": "630-759-8940",
"fax_number": "630-759-9392"
}
],
"practiceLocations": [],
"basic": {
"last_name": "VANDERWALL",
"first_name": "CLAY",
"middle_name": "GORDON",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-08-15",
"last_updated": "2007-08-15",
"status": "A"
},
"taxonomies": [
{
"code": "1223X0400X",
"taxonomy_group": "",
"desc": "Dentist, Orthodontics and Dentofacial Orthopedics",
"state": "IL",
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Bolingbrook, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 15, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.