Healthcare Provider Details

I. General information

NPI: 1972786994
Provider Name (Legal Business Name): TIM HUANG D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2007
Last Update Date: 09/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4045 LONE TREE WAY STE A
ANTIOCH CA
94531-6206
US

IV. Provider business mailing address

4045 LONE TREE WAY STE A
ANTIOCH CA
94531
US

V. Phone/Fax

Practice location:
  • Phone: 310-498-1626
  • Fax:
Mailing address:
  • Phone: 925-706-8688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number55019
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: