Provider Demographics
NPI:1093154791
Name:PHUNG, TRA MY T (DDS)
Entity Type:Individual
Prefix:
First Name:TRA MY
Middle Name:T
Last Name:PHUNG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6417 VIKING TRL
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76001-7903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6901 MCCART AVE
Practice Address - Street 2:#175
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-6377
Practice Address - Country:US
Practice Address - Phone:817-263-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29042122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist