Provider Demographics
NPI:1598200040
Name:KIEU, THAY (RDH)
Entity Type:Individual
Prefix:
First Name:THAY
Middle Name:
Last Name:KIEU
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30035 HAUN RD
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-6805
Mailing Address - Country:US
Mailing Address - Phone:951-566-9090
Mailing Address - Fax:
Practice Address - Street 1:30035 HAUN RD
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584
Practice Address - Country:US
Practice Address - Phone:951-566-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-19
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24963124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA24963Medicaid