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: 07/02/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MERCY CIRCLE
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

4128 RIO AZUL WAY
OCEANSIDE CA
92057-3554
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-5870
  • 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: