Provider Demographics
NPI:1346447828
Name:VAN, JENNIFER T (DMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:T
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 1:2704 CYPRESSWAY CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-8563
Mailing Address - Country:US
Mailing Address - Phone:954-483-8184
Mailing Address - Fax:
Practice Address - Street 1:2050 OLD HICKORY TREE RD
Practice Address - Street 2:SUITE I
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34772-8926
Practice Address - Country:US
Practice Address - Phone:407-556-3969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN180031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice