Healthcare Provider Details

I. General information

NPI: 1922455575
Provider Name (Legal Business Name): ADRIENNE NGOC LAN VAN, DDS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2016
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2114 SENTER RD STE 14
SAN JOSE CA
95112-2608
US

IV. Provider business mailing address

2114 SENTER RD STE 14
SAN JOSE CA
95112-2608
US

V. Phone/Fax

Practice location:
  • Phone: 408-298-8187
  • Fax:
Mailing address:
  • Phone: 408-298-8187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number40506
License Number StateCA

VIII. Authorized Official

Name: DR. ADRIENNE VAN
Title or Position: DENTIST
Credential: DDS
Phone: 408-298-8187