Provider Demographics
NPI:1780252452
Name:TRUONG, KIMBERLY (DMD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:TRUONG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5120 E HAMPTON AVE APT 1061
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-6792
Mailing Address - Country:US
Mailing Address - Phone:714-260-7484
Mailing Address - Fax:
Practice Address - Street 1:825 W SOUTHERN AVE STE 114
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-4720
Practice Address - Country:US
Practice Address - Phone:602-272-1170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0110481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice