Provider Demographics
NPI:1245381003
Name:TRUONG, PHUONGTAM THI (DDS)
Entity Type:Individual
Prefix:
First Name:PHUONGTAM
Middle Name:THI
Last Name:TRUONG
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 1:27 COLONIAL
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620
Mailing Address - Country:US
Mailing Address - Phone:949-290-2558
Mailing Address - Fax:626-284-8148
Practice Address - Street 1:1223 E VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801
Practice Address - Country:US
Practice Address - Phone:626-284-8144
Practice Address - Fax:626-284-8148
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42961122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist