Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 12010771A | IN |
NPI | 1063670883 |
---|---|
Provider Name | Mindy M Van |
First Address | Indianapolis, IN 46260-5381 |
Second Address | Indianapolis, IN 46260-5381 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/05/2008 |
Last Update Date | 29/05/2008 |