Provider Demographics
NPI:1982897534
Name:VONGPHOE, MICHAEL OTTWIT (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:OTTWIT
Last Name:VONGPHOE
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 1:9235 TIMBERLINE LN
Mailing Address - Street 2:APT C
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-6520
Mailing Address - Country:US
Mailing Address - Phone:909-910-2929
Mailing Address - Fax:
Practice Address - Street 1:9235 TIMBERLINE LN
Practice Address - Street 2:APT C
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6520
Practice Address - Country:US
Practice Address - Phone:909-910-2929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55928122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist