Provider Demographics
NPI:1568664498
Name:SENGSOUVANH, VIXIANE (DDS)
Entity Type:Individual
Prefix:
First Name:VIXIANE
Middle Name:
Last Name:SENGSOUVANH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1451
Mailing Address - Street 2:
Mailing Address - City:RANCHO MURIETA
Mailing Address - State:CA
Mailing Address - Zip Code:95683-1451
Mailing Address - Country:US
Mailing Address - Phone:916-354-2637
Mailing Address - Fax:916-354-3270
Practice Address - Street 1:7277 LONE PINE DR.
Practice Address - Street 2:STE. C 105
Practice Address - City:RANCHO MURIETA
Practice Address - State:CA
Practice Address - Zip Code:95683
Practice Address - Country:US
Practice Address - Phone:916-354-2637
Practice Address - Fax:916-354-3270
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48994122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA48994OtherSTATE LICENSE NUMBER