Provider Demographics
NPI:1235287434
Name:PHUONG MY NGO AND CON NGOC TRAN, DDS, INC.
Entity Type:Organization
Organization Name:PHUONG MY NGO AND CON NGOC TRAN, DDS, INC.
Other - Org Name:PC DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CON
Authorized Official - Middle Name:NGOC
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-952-3582
Mailing Address - Street 1:10425 MAGNOLIA AVE #A
Mailing Address - Street 2:SUITE # A
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-5113
Mailing Address - Country:US
Mailing Address - Phone:714-952-3582
Mailing Address - Fax:714-236-5409
Practice Address - Street 1:10425 MAGNOLIA AVE STE A
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-5113
Practice Address - Country:US
Practice Address - Phone:714-952-3582
Practice Address - Fax:714-236-5409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-07
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA441041223G0001X
CA414931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG91567Medicaid
CAG91567-01OtherDENTI-CAL