Provider Demographics
NPI:1801270376
Name:TRUONG, ETHAN (DDS)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:TRUONG
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 1:3433 COVE VIEW BLVD APT 3517
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77554-8188
Mailing Address - Country:US
Mailing Address - Phone:678-200-6508
Mailing Address - Fax:
Practice Address - Street 1:1801 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77550-4912
Practice Address - Country:US
Practice Address - Phone:409-762-8443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-15
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4066122300000X
TX33975122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist