Provider Demographics
NPI:1295628659
Name:VAN, CODY DUC
Entity type:Individual
Prefix:DR
First Name:CODY
Middle Name:DUC
Last Name:VAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2219 E 11TH ST UNIT 204
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-3641
Mailing Address - Country:US
Mailing Address - Phone:316-680-9288
Mailing Address - Fax:
Practice Address - Street 1:1950 W KENOSHA ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-8944
Practice Address - Country:US
Practice Address - Phone:918-518-1526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK80551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty