Provider Demographics
NPI:1164624003
Name:VIXIANE SENGSOUVANH, DDS, INC.
Entity Type:Organization
Organization Name:VIXIANE SENGSOUVANH, DDS, INC.
Other - Org Name:MURIETA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VIXIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:SENGSOUVANH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-354-2637
Mailing Address - Street 1:PO BOX 1451
Mailing Address - Street 2:
Mailing Address - City:RANCHO MURIETA
Mailing Address - State:CA
Mailing Address - Zip Code:95683-1451
Mailing Address - Country:US
Mailing Address - Phone:916-354-2637
Mailing Address - Fax:916-354-3270
Practice Address - Street 1:7277 LONE PINE DR
Practice Address - Street 2:
Practice Address - City:RANCHO MURIETA
Practice Address - State:CA
Practice Address - Zip Code:95683-9715
Practice Address - Country:US
Practice Address - Phone:916-354-2637
Practice Address - Fax:916-354-3270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48994122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty