1639599129 NPI number — HENRY VONG PROF DENTAL CORP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639599129 NPI number — HENRY VONG PROF DENTAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HENRY VONG PROF DENTAL CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639599129
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1771 PLEASANT GROVE BLVD
Provider Second Line Business Mailing Address:
STE 180
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95747-8720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-772-3847
Provider Business Mailing Address Fax Number:
916-273-3111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1771 PLEASANT GROVE BLVD
Provider Second Line Business Practice Location Address:
STE 180
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95747-8720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-772-3847
Provider Business Practice Location Address Fax Number:
916-273-3111
Provider Enumeration Date:
04/23/2014

Additional Information

Authorized Official

Authorized Official Last Name:
VONG
Authorized Official First Name:
HENRY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
415-568-0761

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  60037 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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