Provider Demographics
NPI:1356895882
Name:DOAN, TIEN LOC MAI (DMD)
Entity type:Individual
Prefix:
First Name:TIEN LOC
Middle Name:MAI
Last Name:DOAN
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 1:8148 MONTERRA VILLA TRL
Mailing Address - Street 2:APARTMENT 2935
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76177-6208
Mailing Address - Country:US
Mailing Address - Phone:408-693-4395
Mailing Address - Fax:
Practice Address - Street 1:2308 BARDIN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-3856
Practice Address - Country:US
Practice Address - Phone:972-660-8457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX321861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice