Provider Demographics
NPI:1326677063
Name:TRAN, PAULINE YEN
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:YEN
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 1:43100 PALM ROYALE DR APT 1615
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-4904
Mailing Address - Country:US
Mailing Address - Phone:808-206-4338
Mailing Address - Fax:
Practice Address - Street 1:72333 HIGHWAY 111 STE B
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-2790
Practice Address - Country:US
Practice Address - Phone:760-674-9666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-04
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1065951223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program