Provider Demographics
NPI:1003400656
Name:LUONG, THAO
Entity Type:Individual
Prefix:
First Name:THAO
Middle Name:
Last Name:LUONG
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 1:1873 WESTERN AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-5028
Mailing Address - Country:US
Mailing Address - Phone:518-436-7815
Mailing Address - Fax:
Practice Address - Street 1:1873 WESTERN AVE STE 200
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-5028
Practice Address - Country:US
Practice Address - Phone:518-436-7815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-24
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0626041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice