Provider Demographics
NPI:1164115713
Name:VAN, MINH-TOM (DDS)
Entity Type:Individual
Prefix:DR
First Name:MINH-TOM
Middle Name:
Last Name:VAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12420 W AUBURN AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-4986
Mailing Address - Country:US
Mailing Address - Phone:720-998-2963
Mailing Address - Fax:
Practice Address - Street 1:150 S HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-4817
Practice Address - Country:US
Practice Address - Phone:617-232-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002056371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty