Provider Demographics
NPI:1205967874
Name:VAN, NICOLE (DDS, PC)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:VAN
Suffix:
Gender:F
Credentials:DDS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139A CHURCH ST NW
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4508
Mailing Address - Country:US
Mailing Address - Phone:703-556-0091
Mailing Address - Fax:
Practice Address - Street 1:139A CHURCH ST NW
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4508
Practice Address - Country:US
Practice Address - Phone:703-556-0091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010086331223G0001X
VA06407501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice