Provider Demographics
NPI:1639491657
Name:LONG DANG TRAN D.D.S. , INC
Entity Type:Organization
Organization Name:LONG DANG TRAN D.D.S. , INC
Other - Org Name:UNIVERSITY SQUARE DENTAL, PRACTICE OF LONG DANG TRAN DDS, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LONG
Authorized Official - Middle Name:DANG
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-264-1114
Mailing Address - Street 1:5971 UNIVERSITY AVE STE 309
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-6334
Mailing Address - Country:US
Mailing Address - Phone:619-229-9935
Mailing Address - Fax:
Practice Address - Street 1:5971 UNIVERSITY AVE STE 309
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-6334
Practice Address - Country:US
Practice Address - Phone:619-229-9935
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA511481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1811169568Medicaid