Provider Demographics
NPI:1487174751
Name:VAN, KIM NHI LISA (DDS)
Entity type:Individual
Prefix:
First Name:KIM NHI
Middle Name:LISA
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 1:12255 CLAUDE CT APT 735
Mailing Address - Street 2:
Mailing Address - City:NORTHGLENN
Mailing Address - State:CO
Mailing Address - Zip Code:80241-3340
Mailing Address - Country:US
Mailing Address - Phone:303-717-4652
Mailing Address - Fax:
Practice Address - Street 1:1790 E BRIDGE ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-1934
Practice Address - Country:US
Practice Address - Phone:303-659-1064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002032211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice