=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225062417
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONALD RICHARD VAN BIBBER D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2020 COFFEE RD SUITE J4
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95355-2427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-526-4560
-----------------------------------------------------
Fax | 209-526-4577
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2020 COFFEE RD SUITE J4
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95355-2427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-526-4560
-----------------------------------------------------
Fax | 209-526-4577
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 20283
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------