Provider Demographics
NPI:1700081528
Name:THAY, VICHETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:VICHETH
Middle Name:
Last Name:THAY
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 1:18250 ROSCOE BLVD STE 230
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-4269
Mailing Address - Country:US
Mailing Address - Phone:818-885-1981
Mailing Address - Fax:818-885-1937
Practice Address - Street 1:18250 ROSCOE BLVD STE 230
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-4269
Practice Address - Country:US
Practice Address - Phone:818-885-1981
Practice Address - Fax:818-885-1937
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46531122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist