Provider Demographics
NPI:1003458126
Name:VAN, ELIZABETH HONG (DDS)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:HONG
Last Name:VAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34400 ORSINI DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-5774
Mailing Address - Country:US
Mailing Address - Phone:586-744-9869
Mailing Address - Fax:
Practice Address - Street 1:34400 ORSINI DR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-5774
Practice Address - Country:US
Practice Address - Phone:586-744-9869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901600360122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist