Provider Demographics
NPI:1003222472
Name:KIEU, MINH-PHUONG ISABELLE
Entity Type:Individual
Prefix:
First Name:MINH-PHUONG ISABELLE
Middle Name:
Last Name:KIEU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LAFAYETTE PLAISANCE ST APT 609
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-2821
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2700 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-2576
Practice Address - Country:US
Practice Address - Phone:313-494-6629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-07
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021361122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist