Provider Demographics
NPI:1316193501
Name:LE, NGA NGOC KIM
Entity Type:Individual
Prefix:DR
First Name:NGA NGOC
Middle Name:KIM
Last Name:LE
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 1:990 HIGHWAY 287 N
Mailing Address - Street 2:SUITE 112
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-2607
Mailing Address - Country:US
Mailing Address - Phone:817-473-6677
Mailing Address - Fax:817-473-6695
Practice Address - Street 1:990 HIGHWAY 287 N
Practice Address - Street 2:SUITE 112
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-2607
Practice Address - Country:US
Practice Address - Phone:817-473-6677
Practice Address - Fax:817-473-6695
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19397122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist