Provider Demographics
NPI:1851415319
Name:LE, PHUONG B (DMD)
Entity Type:Individual
Prefix:
First Name:PHUONG
Middle Name:B
Last Name:LE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2993 ARBOR CHASE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-1800
Mailing Address - Country:US
Mailing Address - Phone:770-908-8711
Mailing Address - Fax:
Practice Address - Street 1:3985 STEVE REYNOLDS BLVD
Practice Address - Street 2:BUILDING O, SUITE 101
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-3035
Practice Address - Country:US
Practice Address - Phone:678-205-1308
Practice Address - Fax:678-205-1345
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0133691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice