Healthcare Provider Details

I. General information

NPI: 1558457473
Provider Name (Legal Business Name): HUAN VAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 08/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5202 SILVER ACRES CT
SAN JOSE CA
95138-2102
US

IV. Provider business mailing address

5202 SILVER ACRES CT
SAN JOSE CA
95138-2102
US

V. Phone/Fax

Practice location:
  • Phone: 408-256-0307
  • Fax:
Mailing address:
  • Phone: 408-449-2812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number52014
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: