Provider Demographics
NPI:1700317294
Name:TRAN, JIMMY (DDS)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:
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 1:12621 STARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-5367
Mailing Address - Country:US
Mailing Address - Phone:714-390-9579
Mailing Address - Fax:
Practice Address - Street 1:5371 HIGHWAY 49 N
Practice Address - Street 2:
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95338-9503
Practice Address - Country:US
Practice Address - Phone:209-742-7788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-25
Last Update Date:2017-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100894122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist