Provider Demographics
NPI:1255408456
Name:VUONG, VINH TU
Entity type:Individual
Prefix:
First Name:VINH
Middle Name:TU
Last Name:VUONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3111
Mailing Address - Country:US
Mailing Address - Phone:719-583-1800
Mailing Address - Fax:
Practice Address - Street 1:1631 GORDON HWY
Practice Address - Street 2:#22
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-2292
Practice Address - Country:US
Practice Address - Phone:706-790-9302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0134511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice