MEDICARE: DR. ARJEN L VAN DE VOORDE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	14707	TX

General Provider Information

NPI Number	:	1154391027
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ARJEN L VAN DE VOORDE DDS

Provider Business Mailing Address
First Line	:	823 LAKE AMICK DR
Second Line	:
City	:	NICEVILLE
State	:	FL
Zip	:	32578-1739
Country	:	US
Telephone Number	:	850-892-8015
Fax Number	:

Provider Business Practice Location Address
First Line	:	362 STATE HIGHWAY 83
Second Line	:
City	:	DEFUNIAK SPRINGS
State	:	FL
Zip	:	32433
Country	:	US
Telephone Number	:	850-892-8015
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2006
Last Update Date	:	12/27/2010

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