Provider Demographics
NPI:1912223439
Name:LE QUANG, MATHIEU (DDS)
Entity Type:Individual
Prefix:
First Name:MATHIEU
Middle Name:
Last Name:LE QUANG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:MATHIEU
Other - Middle Name:
Other - Last Name:LEQUANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:1801 NEWPORT BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-2701
Mailing Address - Country:US
Mailing Address - Phone:949-645-6631
Mailing Address - Fax:949-645-2051
Practice Address - Street 1:1801 NEWPORT BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-2701
Practice Address - Country:US
Practice Address - Phone:949-645-6631
Practice Address - Fax:949-645-2051
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-08
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA462871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice