Provider Demographics
NPI:1457196438
Name:TRAN, KHANG BAO (DDS)
Entity type:Individual
Prefix:
First Name:KHANG
Middle Name:BAO
Last Name:TRAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 BOONE AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-7006
Mailing Address - Country:US
Mailing Address - Phone:616-350-8588
Mailing Address - Fax:
Practice Address - Street 1:4611 N BRETON CT SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-5211
Practice Address - Country:US
Practice Address - Phone:616-656-5776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901602274122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist