Provider Demographics
NPI:1720091705
Name:PHAN, CUONG TIEN
Entity Type:Individual
Prefix:
First Name:CUONG
Middle Name:TIEN
Last Name:PHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CUONG
Other - Middle Name:TIEN
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:7824 LAKE UNDERHILL RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-8201
Mailing Address - Country:US
Mailing Address - Phone:407-282-7498
Mailing Address - Fax:407-658-2379
Practice Address - Street 1:7824 LAKE UNDERHILL RD
Practice Address - Street 2:SUITE G
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-8201
Practice Address - Country:US
Practice Address - Phone:407-282-7498
Practice Address - Fax:407-658-2379
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15320122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist