Basic Information
Provider Information
NPI: 1003292491
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TRAN
FirstName: VAN
MiddleName: THANH
NamePrefix:  
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 5302 HARBOR TOWN DR
Address2:  
City: DALLAS
State: TX
PostalCode: 752877319
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 3464 WEBB CHAPEL EXT
Address2:  
City: DALLAS
State: TX
PostalCode: 752206751
CountryCode: US
TelephoneNumber: 2146352810
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/07/2015
LastUpdateDate: 08/07/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X31157TXY Dental ProvidersDentist 

No ID Information.


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