Provider Demographics
NPI:1134571904
Name:VAN, JULIE (DMD)
Entity type:Individual
Prefix:DR
First Name:JULIE
Middle Name:
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 1:10882 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:CA
Mailing Address - Zip Code:90680-3056
Mailing Address - Country:US
Mailing Address - Phone:714-404-3973
Mailing Address - Fax:
Practice Address - Street 1:2133 PEPPERRELL ST BLDG 3352
Practice Address - Street 2:
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-5313
Practice Address - Country:US
Practice Address - Phone:210-292-6258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-05
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1003331223G0001X
FLDTC711223G0001X
TX373071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice