Healthcare Provider Details

I. General information

NPI: 1033038815
Provider Name (Legal Business Name): JENNIFER NGOC BUI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82151 AVENUE 42 STE 110
INDIO CA
92203-9313
US

IV. Provider business mailing address

12531 BLACKTHORN ST
GARDEN GROVE CA
92840-4802
US

V. Phone/Fax

Practice location:
  • Phone: 760-255-7597
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number113283
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: