Provider Demographics
NPI:1598819625
Name:SU, TUAN DI (DDS)
Entity Type:Individual
Prefix:
First Name:TUAN
Middle Name:DI
Last Name:SU
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 1:3043 OLD DENTON RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75007-5036
Mailing Address - Country:US
Mailing Address - Phone:972-567-7450
Mailing Address - Fax:
Practice Address - Street 1:3043 OLD DENTON RD
Practice Address - Street 2:STE. 108
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75007-5036
Practice Address - Country:US
Practice Address - Phone:972-492-5838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX204761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144548802Medicaid
TX149824801Medicaid