Provider Demographics
NPI:1649406133
Name:1692 TULLY DENTISTRY
Entity Type:Organization
Organization Name:1692 TULLY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:PHUNG
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-279-2114
Mailing Address - Street 1:1692 TULLY ROAD
Mailing Address - Street 2:#4
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95122
Mailing Address - Country:US
Mailing Address - Phone:408-223-6953
Mailing Address - Fax:408-223-0749
Practice Address - Street 1:2114 SENIOR ROAD
Practice Address - Street 2:SUITE 25
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112
Practice Address - Country:US
Practice Address - Phone:408-279-2114
Practice Address - Fax:408-279-1828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-10
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44749122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty