Provider Demographics
NPI:1083052641
Name:TONGOC, MELANIE THIENTHAO
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:THIENTHAO
Last Name:TONGOC
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 1:16678 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-2233
Mailing Address - Country:US
Mailing Address - Phone:714-531-7050
Mailing Address - Fax:
Practice Address - Street 1:6012 FLORENCE AVE
Practice Address - Street 2:#B
Practice Address - City:BELL GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90201-4737
Practice Address - Country:US
Practice Address - Phone:714-598-5420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62903122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program