Provider Demographics
NPI:1053463794
Name:LE, QUANG BAO (DDS)
Entity Type:Individual
Prefix:DR
First Name:QUANG
Middle Name:BAO
Last Name:LE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 N SANTA FE AVE
Mailing Address - Street 2:SUITE #114
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-3206
Mailing Address - Country:US
Mailing Address - Phone:760-732-5878
Mailing Address - Fax:760-732-5939
Practice Address - Street 1:1234 N SANTA FE AVE
Practice Address - Street 2:SUITE #114
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-3206
Practice Address - Country:US
Practice Address - Phone:760-732-5878
Practice Address - Fax:760-732-5939
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA497741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG98624-01OtherDELTA DENTAL HFP