Provider Demographics
NPI:1164872578
Name:VAN, PHUONG KIM (DMD)
Entity Type:Individual
Prefix:DR
First Name:PHUONG KIM
Middle Name:
Last Name:VAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3185 CITRUS TOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-6803
Mailing Address - Country:US
Mailing Address - Phone:352-247-8471
Mailing Address - Fax:
Practice Address - Street 1:3185 CITRUS TOWER BLVD
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6803
Practice Address - Country:US
Practice Address - Phone:352-271-8471
Practice Address - Fax:352-271-8472
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 218871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice