Provider Demographics
NPI:1942296942
Name:VAN, VINCENT T (DMD)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:T
Last Name:VAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:VINCENT
Other - Middle Name:T
Other - Last Name:VAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:8749 THE ESPLANADE APT 27
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32836-7736
Mailing Address - Country:US
Mailing Address - Phone:503-750-9718
Mailing Address - Fax:
Practice Address - Street 1:5316 CENTRAL FLORIDA PKWY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32821-8772
Practice Address - Country:US
Practice Address - Phone:407-239-9557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-25
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD 82931223G0001X
FLDN195341223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004545000Medicaid