Provider Demographics
NPI:1437535325
Name:VAN GALDER, DANIEL
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:VAN GALDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 N MARIETTA PKWY NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1545
Mailing Address - Country:US
Mailing Address - Phone:770-426-0288
Mailing Address - Fax:
Practice Address - Street 1:361 N MARIETTA PKWY NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1545
Practice Address - Country:US
Practice Address - Phone:770-426-0288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015034122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist