Healthcare Provider Details

I. General information

NPI: 1710326236
Provider Name (Legal Business Name): JIMMY DUONG D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 11/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WILSHIRE BLVD BUILDING 500, DENTAL CLINIC
LOS ANGELES CA
90073-1003
US

IV. Provider business mailing address

1873 VETERAN AVE APT 8
LOS ANGELES CA
90025-4585
US

V. Phone/Fax

Practice location:
  • Phone: 310-268-3776
  • Fax:
Mailing address:
  • Phone: 408-230-0196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number64196
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: