Provider Demographics
NPI:1982043451
Name:VAN, PHU (DMD)
Entity Type:Individual
Prefix:
First Name:PHU
Middle Name:
Last Name:VAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 SW 94TH TER
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025-1152
Mailing Address - Country:US
Mailing Address - Phone:813-381-5632
Mailing Address - Fax:
Practice Address - Street 1:2050 OLD HICKORY TREE RD
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34772-8926
Practice Address - Country:US
Practice Address - Phone:954-579-1843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20156122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist