Provider Demographics
NPI:1619313343
Name:LE, THAO PHUOC (DDS)
Entity Type:Individual
Prefix:
First Name:THAO
Middle Name:PHUOC
Last Name:LE
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 1:7317 OAKLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4144
Mailing Address - Country:US
Mailing Address - Phone:920-661-7520
Mailing Address - Fax:
Practice Address - Street 1:6411 RICHFIELD PKWY
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-6400
Practice Address - Country:US
Practice Address - Phone:612-869-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14132122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist