Provider Demographics
NPI:1013574284
Name:SYBO, BAO TRUC
Entity Type:Individual
Prefix:
First Name:BAO TRUC
Middle Name:
Last Name:SYBO
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 1:1400 ROSA L PARKS BLVD APT 217
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37208-2571
Mailing Address - Country:US
Mailing Address - Phone:504-723-4028
Mailing Address - Fax:
Practice Address - Street 1:4502 CHARLOTTE PIKE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37209
Practice Address - Country:US
Practice Address - Phone:615-933-1981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23587122300000X
TN11157122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist