Provider Demographics
NPI:1639327836
Name:LE, TOMMY
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:
Last Name:LE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1712 S GREENVILLE ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-4004
Mailing Address - Country:US
Mailing Address - Phone:714-571-3682
Mailing Address - Fax:
Practice Address - Street 1:1712 S GREENVILLE ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-4004
Practice Address - Country:US
Practice Address - Phone:714-571-3682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57630122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist