Provider Demographics
NPI:1871887497
Name:VANDEVELDE, DYAN MARIE (DMD)
Entity type:Individual
Prefix:DR
First Name:DYAN
Middle Name:MARIE
Last Name:VANDEVELDE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MRS
Other - First Name:DYAN
Other - Middle Name:VAN DE VELDE
Other - Last Name:POUCHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2325 PALOS VERDES DR W STE 210
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-2787
Mailing Address - Country:US
Mailing Address - Phone:310-377-6580
Mailing Address - Fax:310-377-3838
Practice Address - Street 1:2325 PALOS VERDES DR W STE 210
Practice Address - Street 2:
Practice Address - City:PALOS VERDES ESTATES
Practice Address - State:CA
Practice Address - Zip Code:90274-2787
Practice Address - Country:US
Practice Address - Phone:310-377-6580
Practice Address - Fax:310-377-3838
Is Sole Proprietor?:No
Enumeration Date:2011-05-31
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA295121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice