Provider Demographics
NPI:1639599129
Name:HENRY VONG PROF DENTAL CORP
Entity Type:Organization
Organization Name:HENRY VONG PROF DENTAL CORP
Other - Org Name:ROSEVILLE DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:VONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:415-568-0761
Mailing Address - Street 1:1771 PLEASANT GROVE BLVD
Mailing Address - Street 2:STE 180
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-8720
Mailing Address - Country:US
Mailing Address - Phone:916-772-3847
Mailing Address - Fax:916-273-3111
Practice Address - Street 1:1771 PLEASANT GROVE BLVD
Practice Address - Street 2:STE 180
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-8720
Practice Address - Country:US
Practice Address - Phone:916-772-3847
Practice Address - Fax:916-273-3111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60037261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental