Provider Demographics
NPI:1376039024
Name:NGUYEN, PHUONG THAO TRAN (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:PHUONG THAO
Middle Name:TRAN
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2168 SKYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-2638
Mailing Address - Country:US
Mailing Address - Phone:832-566-7358
Mailing Address - Fax:
Practice Address - Street 1:2168 SKYVIEW DR
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-2638
Practice Address - Country:US
Practice Address - Phone:770-739-5097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-05
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA69041223G0001X
GADN1222781223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No1223G0001XDental ProvidersDentistGeneral Practice