Provider Demographics
NPI:1245683382
Name:TRAN TRUONG DDS A PROFESSIONAL CORP.
Entity type:Organization
Organization Name:TRAN TRUONG DDS A PROFESSIONAL CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-267-9163
Mailing Address - Street 1:80120 US HIGHWAY 111
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-8364
Mailing Address - Country:US
Mailing Address - Phone:760-775-9901
Mailing Address - Fax:760-775-9902
Practice Address - Street 1:80120 US HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-8364
Practice Address - Country:US
Practice Address - Phone:760-775-9901
Practice Address - Fax:760-775-9902
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRAN TRUONG DDS A PROFESSIONAL CORP.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA459931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1831323559Medicaid
CAB45993-01OtherDENTICAL