Provider Demographics
NPI:1326825787
Name:VAN, TAI CONG (DDS)
Entity Type:Individual
Prefix:DR
First Name:TAI
Middle Name:CONG
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 1:12205 STUART DR
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-0362
Mailing Address - Country:US
Mailing Address - Phone:941-275-4629
Mailing Address - Fax:
Practice Address - Street 1:12205 STUART DR
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-0362
Practice Address - Country:US
Practice Address - Phone:941-275-4629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN28224122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist