Healthcare Provider Details

I. General information

NPI: 1497449037
Provider Name (Legal Business Name): THEODORE TRAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15317 W BELL RD STE 108
SURPRISE AZ
85374-3901
US

IV. Provider business mailing address

3033 N CENTRAL AVE STE 145
PHOENIX AZ
85012-2808
US

V. Phone/Fax

Practice location:
  • Phone: 877-809-5092
  • Fax: 623-214-5231
Mailing address:
  • Phone: 623-583-3001
  • Fax: 623-583-3007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD011795
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD011795
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: