Provider Demographics
NPI:1073787321
Name:VUONG, PHUOC THANH (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:PHUOC
Middle Name:THANH
Last Name:VUONG
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 CONSERVATORY LN
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60502-8913
Mailing Address - Country:US
Mailing Address - Phone:630-862-5169
Mailing Address - Fax:
Practice Address - Street 1:220 E PLEASANT ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-3532
Practice Address - Country:US
Practice Address - Phone:414-435-5850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0259581223G0001X
WI6861-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice