Provider Demographics
NPI:1497105175
Name:OLD TOWNE DENTAL GROUP
Entity Type:Organization
Organization Name:OLD TOWNE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THU
Authorized Official - Middle Name:ANH
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:714-288-0058
Mailing Address - Street 1:262 S GLASSELL ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92866-1918
Mailing Address - Country:US
Mailing Address - Phone:714-288-0058
Mailing Address - Fax:714-288-0061
Practice Address - Street 1:262 S GLASSELL ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-1918
Practice Address - Country:US
Practice Address - Phone:714-288-0058
Practice Address - Fax:714-288-0061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty