Provider Demographics
NPI:1558889055
Name:LE, VIVIAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:
Last Name:LE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9561 INGRAM AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92844-2922
Mailing Address - Country:US
Mailing Address - Phone:714-383-0891
Mailing Address - Fax:
Practice Address - Street 1:424 S MAIN ST STE H
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3828
Practice Address - Country:US
Practice Address - Phone:714-426-9577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101639122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist