Provider Demographics
NPI:1972952448
Name:MAI, HIEU TRUNG (DMD)
Entity Type:Individual
Prefix:
First Name:HIEU
Middle Name:TRUNG
Last Name:MAI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11695 SLATE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-5197
Mailing Address - Country:US
Mailing Address - Phone:951-353-0050
Mailing Address - Fax:951-353-0060
Practice Address - Street 1:11695 SLATE AVE STE 200
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-5197
Practice Address - Country:US
Practice Address - Phone:951-353-0050
Practice Address - Fax:951-353-0060
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44933122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
44933OtherDENTAL BOARD