Provider Demographics
NPI:1518313154
Name:DUONG, PHUC BA (DDS)
Entity Type:Individual
Prefix:
First Name:PHUC
Middle Name:BA
Last Name:DUONG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:PHILLIP
Other - Middle Name:
Other - Last Name:DUONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:1714 LIPSCOMB ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1456
Mailing Address - Country:US
Mailing Address - Phone:714-360-7716
Mailing Address - Fax:
Practice Address - Street 1:1714 LIPSCOMB ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1456
Practice Address - Country:US
Practice Address - Phone:714-360-7716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program