Provider Demographics
NPI:1093274250
Name:MAI, TUONGVI CUNG
Entity Type:Individual
Prefix:MISS
First Name:TUONGVI
Middle Name:CUNG
Last Name:MAI
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:TIFFANY
Other - Middle Name:CUNG
Other - Last Name:MAI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4645 CAMDEN DR
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-3104
Mailing Address - Country:US
Mailing Address - Phone:714-889-8013
Mailing Address - Fax:
Practice Address - Street 1:1200 NORTH STATE ST
Practice Address - Street 2:CLINIC TOWER SUITE A7D
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1029
Practice Address - Country:US
Practice Address - Phone:714-889-8013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1055521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice