Provider Demographics
NPI:1063082170
Name:TRAN, TONY VAN (DMD)
Entity type:Individual
Prefix:
First Name:TONY
Middle Name:VAN
Last Name:TRAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 PENNSYLVANIA AVE UNIT 512
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-4662
Mailing Address - Country:US
Mailing Address - Phone:912-441-5573
Mailing Address - Fax:
Practice Address - Street 1:885 WESTERN AVE STE 300
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-3874
Practice Address - Country:US
Practice Address - Phone:920-923-6766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002615-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice