Provider Demographics
NPI:1194203166
Name:TRAN, PHUONG
Entity Type:Individual
Prefix:
First Name:PHUONG
Middle Name:
Last Name:TRAN
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 1:6712 NW 112TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-2978
Mailing Address - Country:US
Mailing Address - Phone:405-887-3267
Mailing Address - Fax:
Practice Address - Street 1:7223 MISSISSIPPI AVE BLDG 1561
Practice Address - Street 2:
Practice Address - City:FT. POLK
Practice Address - State:LA
Practice Address - Zip Code:71459-5110
Practice Address - Country:US
Practice Address - Phone:337-531-2327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK70731223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice