MEDICARE: ELAINE L. VAN, DDS

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	122300000X	Dentist	42621	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1497801336	OTHER	CA	DENTI-CAL

General Provider Information

NPI Number	:	1316342694
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELAINE L. VAN, DDS

Provider Business Mailing Address
First Line	:	17020 CONDIT RD
Second Line	:	#180
City	:	MORGAN HILL
State	:	CA
Zip	:	95037-7229
Country	:	US
Telephone Number	:	408-778-4548
Fax Number	:	408-778-4648

Provider Business Practice Location Address
First Line	:	17020 CONDIT RD
Second Line	:	#180
City	:	MORGAN HILL
State	:	CA
Zip	:	95037-7229
Country	:	US
Telephone Number	:	408-778-4548
Fax Number	:	408-778-4648

Authorized Official
Title or Position	:	OWNER
Name	:	ELAINE L VAN
Credential	:	DDS
Telephone Number	:	408-778-4548

Provider Enumeration Date	:	10/29/2014
Last Update Date	:	10/29/2014

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