Provider Demographics
NPI:1942370317
Name:NGUYEN AND TA PROFESSIONAL DENTAL CORP.
Entity Type:Organization
Organization Name:NGUYEN AND TA PROFESSIONAL DENTAL CORP.
Other - Org Name:THAI TA, DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:THAI
Authorized Official - Middle Name:THUY
Authorized Official - Last Name:TA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-337-4440
Mailing Address - Street 1:1740 W CAMERON AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2719
Mailing Address - Country:US
Mailing Address - Phone:626-337-4440
Mailing Address - Fax:626-337-4460
Practice Address - Street 1:1740 W CAMERON AVE STE 106
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2719
Practice Address - Country:US
Practice Address - Phone:626-337-4440
Practice Address - Fax:626-337-4460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA455301223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty