Provider Demographics
NPI:1164115713
Name:VAN, MINH-TOM (DDS)
Entity type:Individual
Prefix:DR
First Name:MINH-TOM
Middle Name:
Last Name:VAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12420 W AUBURN AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-4986
Mailing Address - Country:US
Mailing Address - Phone:720-998-2963
Mailing Address - Fax:
Practice Address - Street 1:4516 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-1513
Practice Address - Country:US
Practice Address - Phone:562-437-0647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002056371223G0001X
CA1105031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty