MEDICARE: VIXIANE SENGSOUVANH DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	48994	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	48994	OTHER	CA	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1568664498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIXIANE SENGSOUVANH DDS

Provider Business Mailing Address
First Line	:	PO BOX 1451
Second Line	:
City	:	RANCHO MURIETA
State	:	CA
Zip	:	95683-1451
Country	:	US
Telephone Number	:	916-354-2637
Fax Number	:	916-354-3270

Provider Business Practice Location Address
First Line	:	7277 LONE PINE DR.
Second Line	:	STE. C 105
City	:	RANCHO MURIETA
State	:	CA
Zip	:	95683
Country	:	US
Telephone Number	:	916-354-2637
Fax Number	:	916-354-3270

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2007
Last Update Date	:	07/08/2007

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