Provider Demographics
NPI:1508596768
Name:VAN DE WATER, LAURA (DMD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:VAN DE WATER
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:PO BOX 780174
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32878-0174
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10429 MOSS PARK RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32832-5812
Practice Address - Country:US
Practice Address - Phone:407-277-1779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-12
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26888122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist