Healthcare Provider Details

I. General information

NPI: 1376432302
Provider Name (Legal Business Name): ETHAN THIEN TA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2025
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 475 BOX 1
FPO AP
96350-1200
US

IV. Provider business mailing address

15290 DUNDEE AVE
APPLE VALLEY MN
55124-5889
US

V. Phone/Fax

Practice location:
  • Phone: 315-243-7144
  • Fax:
Mailing address:
  • Phone: 952-649-1301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number111703
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: