Provider Demographics
NPI:1265660211
Name:LE, AN NGUYEN PHUC (DMD)
Entity Type:Individual
Prefix:DR
First Name:AN
Middle Name:NGUYEN PHUC
Last Name:LE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2129 LUZ AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-2045
Mailing Address - Country:US
Mailing Address - Phone:617-538-1007
Mailing Address - Fax:
Practice Address - Street 1:2129 LUZ AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-2045
Practice Address - Country:US
Practice Address - Phone:617-538-1007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA596211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice