Provider Demographics
NPI:1043449556
Name:DUONG, THAIDA (DMD)
Entity Type:Individual
Prefix:
First Name:THAIDA
Middle Name:
Last Name:DUONG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 SUMNER AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01108-2458
Mailing Address - Country:US
Mailing Address - Phone:413-739-1100
Mailing Address - Fax:413-737-3608
Practice Address - Street 1:532 SUMNER AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01108-2458
Practice Address - Country:US
Practice Address - Phone:413-739-1100
Practice Address - Fax:413-737-3608
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1855116122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1310097Medicaid