Provider Demographics
NPI:1669491817
Name:VAN, KIM THI (DMD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:THI
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 1:2717 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-3041
Mailing Address - Country:US
Mailing Address - Phone:817-924-7670
Mailing Address - Fax:817-942-7646
Practice Address - Street 1:2717 8TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-3041
Practice Address - Country:US
Practice Address - Phone:817-924-7670
Practice Address - Fax:817-924-7646
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23133122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist