Provider Demographics
NPI:1205406915
Name:VAN SICKLEN DDS INC
Entity Type:Organization
Organization Name:VAN SICKLEN DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:NEAL
Authorized Official - Last Name:VAN SICKLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:209-607-6956
Mailing Address - Street 1:9591 RUFF AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95212-2417
Mailing Address - Country:US
Mailing Address - Phone:209-607-6956
Mailing Address - Fax:
Practice Address - Street 1:1372 W ROBINHOOD DR STE A
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5513
Practice Address - Country:US
Practice Address - Phone:209-607-6956
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-26
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental