Healthcare Provider Details

I. General information

NPI: 1609437797
Provider Name (Legal Business Name): BRADLEY DINH TRUONG DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 03/21/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CMR 402 UNIT 33100
APO AE
09180
US

IV. Provider business mailing address

CMR 467 BOX 6323
APO AE
09096-0064
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-1515
  • Fax:
Mailing address:
  • Phone: 832-454-7485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7251
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: