Provider Demographics
NPI:1811050917
Name:TA, PHUONG HELENE (DDS)
Entity type:Individual
Prefix:DR
First Name:PHUONG
Middle Name:HELENE
Last Name:TA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 BUENOS AIRES BLVD STE 125
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-6826
Mailing Address - Country:US
Mailing Address - Phone:352-753-5838
Mailing Address - Fax:352-391-5837
Practice Address - Street 1:36800 WINFIELD CT
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32735-9131
Practice Address - Country:US
Practice Address - Phone:352-255-5538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN146681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice