Healthcare Provider Details

I. General information

NPI: 1790470003
Provider Name (Legal Business Name): NGOC-THANH TIEU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENINE TIEU

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10022 IMPERIAL AVE STE A
GARDEN GROVE CA
92843-2371
US

IV. Provider business mailing address

10022 IMPERIAL AVE STE A
GARDEN GROVE CA
92843-2371
US

V. Phone/Fax

Practice location:
  • Phone: 714-534-6969
  • Fax:
Mailing address:
  • Phone: 714-534-6969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number113566
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: