Provider Demographics
NPI:1780667386
Name:MICHELLE MYCHAU TRAN, D.D.S., A PROFESSIONAL DENTAL CORP.
Entity type:Organization
Organization Name:MICHELLE MYCHAU TRAN, D.D.S., A PROFESSIONAL DENTAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:MYCHAU
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-372-3600
Mailing Address - Street 1:12683 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:CA
Mailing Address - Zip Code:90680-4007
Mailing Address - Country:US
Mailing Address - Phone:714-372-3600
Mailing Address - Fax:714-372-3705
Practice Address - Street 1:12683 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:CA
Practice Address - Zip Code:90680-4007
Practice Address - Country:US
Practice Address - Phone:714-372-3600
Practice Address - Fax:714-372-3705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA462251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93104-01Medicaid