Provider Demographics
NPI:1073736807
Name:VAN WORMER, DAVID L
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:VAN WORMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 NORTH LAKE ST.
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580
Mailing Address - Country:US
Mailing Address - Phone:574-269-1952
Mailing Address - Fax:
Practice Address - Street 1:312 NORTH LAKE ST.
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580
Practice Address - Country:US
Practice Address - Phone:574-269-1952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009888122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist