Provider Demographics
NPI:1154739381
Name:VAN-DAO, INC
Entity type:Organization
Organization Name:VAN-DAO, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:VANDENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-722-7767
Mailing Address - Street 1:12321 HIDDEN FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-2578
Mailing Address - Country:US
Mailing Address - Phone:405-722-7767
Mailing Address - Fax:405-722-8858
Practice Address - Street 1:12321 HIDDEN FOREST BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-2578
Practice Address - Country:US
Practice Address - Phone:405-722-7767
Practice Address - Fax:405-722-8858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK51321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty