Provider Demographics
NPI:1952769465
Name:VAN, LAURA VY (DDS)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:VY
Last Name:VAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:969 HILGARD AVE APT 1201
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-3002
Mailing Address - Country:US
Mailing Address - Phone:714-272-2797
Mailing Address - Fax:
Practice Address - Street 1:3932 WILSHIRE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-3307
Practice Address - Country:US
Practice Address - Phone:213-386-3336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-29
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1011471223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1992892616Medicaid