Provider Demographics
NPI:1003953563
Name:TA, THAI THUY (DDS)
Entity Type:Individual
Prefix:
First Name:THAI
Middle Name:THUY
Last Name:TA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 W CAMERON AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2719
Mailing Address - Country:US
Mailing Address - Phone:626-337-4440
Mailing Address - Fax:
Practice Address - Street 1:1740 W CAMERON AVE STE 106
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2719
Practice Address - Country:US
Practice Address - Phone:626-337-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA455301223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA445530OtherG.G. DELTA