MEDICARE: SOKPHEAP PREAP RDH

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	124Q00000X	Dental Hygienist	26589	CA

General Provider Information

NPI Number	:	1932840634
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOKPHEAP PREAP RDH

Provider Business Mailing Address
First Line	:	1401 MAYFIELD WAY
Second Line	:
City	:	TUSTIN
State	:	CA
Zip	:	92782-1787
Country	:	US
Telephone Number	:	562-537-8375
Fax Number	:

Provider Business Practice Location Address
First Line	:	5500 E ATHERTON ST STE 430
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90815-4018
Country	:	US
Telephone Number	:	562-537-8375
Fax Number	:

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

Provider Enumeration Date	:	04/05/2022
Last Update Date	:	04/05/2022

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