Healthcare Provider Details

I. General information

NPI: 1548452774
Provider Name (Legal Business Name): QUYNH-THU THAI, D.D.S., A PROF. CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2007
Last Update Date: 08/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 S MAIN AVE SUITE J
FALLBROOK CA
92028-3351
US

IV. Provider business mailing address

855 S MAIN AVE SUITE J
FALLBROOK CA
92028-3351
US

V. Phone/Fax

Practice location:
  • Phone: 760-723-8599
  • Fax: 760-723-6289
Mailing address:
  • Phone: 760-723-8599
  • Fax: 760-723-6289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number37372
License Number StateCA

VIII. Authorized Official

Name: DR. QUYNH-THU THAI
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 760-723-8599