Provider Demographics
NPI:1801881743
Name:VAN, JOHN PHU (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PHU
Last Name:VAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13722 TYPEE WAY
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-3272
Mailing Address - Country:US
Mailing Address - Phone:949-500-4303
Mailing Address - Fax:714-242-1777
Practice Address - Street 1:12555 GARDEN GROVE BLVD
Practice Address - Street 2:SUITE 308
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1902
Practice Address - Country:US
Practice Address - Phone:714-534-1434
Practice Address - Fax:714-242-1777
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB36333-02Medicaid