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General NPI Number Information
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NPI Number | 1174009070
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Entity Type | Individual
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Provider Name | KIM T VAN
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Gender | Female
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Dates
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Enumeration Date | 07/13/2018
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Last Update Date | 07/24/2018
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Provider Practice Location Address
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Address Line | 1907 HUGUENOT RD
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23235
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Country | US
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Telephone | 804-379-6806
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Fax |
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Provider Business Mailing Address
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Address Line | 1907 HUGUENOT RD
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23235-4325
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Country | US
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Telephone | 804-379-6806
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 0401416121
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License Number State | VA
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