Provider Demographics
NPI:1740365873
Name:VAN DERSCHELDEN, LARAE
Entity type:Individual
Prefix:DR
First Name:LARAE
Middle Name:
Last Name:VAN DERSCHELDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17917 BOTHELL EVERETT HWY
Mailing Address - Street 2:SUITE 305
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98012-6384
Mailing Address - Country:US
Mailing Address - Phone:425-481-1038
Mailing Address - Fax:425-483-3158
Practice Address - Street 1:17917 BOTHELL EVERETT HWY
Practice Address - Street 2:SUITE 305
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98012-6384
Practice Address - Country:US
Practice Address - Phone:425-481-1038
Practice Address - Fax:425-483-3158
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6076122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist