Provider Demographics
NPI:1811553076
Name:VAN, CONNOR (DMD)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:VAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:CONNOR
Other - Middle Name:
Other - Last Name:VAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:7651 ASHLEY PARK CT STE 406
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-6114
Mailing Address - Country:US
Mailing Address - Phone:407-794-1901
Mailing Address - Fax:
Practice Address - Street 1:7651 ASHLEY PARK CT STE 406
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-6114
Practice Address - Country:US
Practice Address - Phone:617-416-8016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-14
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN241471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice