MEDICARE: VAN DUKER PEDIATRIC PLLC

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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1578331633
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VAN DUKER PEDIATRIC PLLC

Provider Business Mailing Address
First Line	:	653 S BEEBE ST
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85296-0131
Country	:	US
Telephone Number	:	253-549-8789
Fax Number	:

Provider Business Practice Location Address
First Line	:	5505 S LINDSAY
Second Line	:	SUITE 105
City	:	GILBERT
State	:	AZ
Zip	:	85298-8529
Country	:	US
Telephone Number	:	253-549-8789
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MARK VAN DUKER
Credential	:	DDS
Telephone Number	:	253-549-8789

Provider Enumeration Date	:	12/18/2023
Last Update Date	:	12/18/2023

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