Basic Information
Provider Information
NPI: 1699969378
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TRUONG
FirstName: PHU
MiddleName: VINH
NamePrefix:  
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1412 S KENMORE ST
Address2:  
City: ANAHEIM
State: CA
PostalCode: 928045127
CountryCode: US
TelephoneNumber: 7145885605
FaxNumber:  
Practice Location
Address1: 2737 W. CECIL
Address2:  
City: DELANO
State: CA
PostalCode: 93216
CountryCode: US
TelephoneNumber: 6617212345
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/05/2007
LastUpdateDate: 09/05/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X53283CAY Dental ProvidersDentist 

No ID Information.


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