Healthcare Provider Details

I. General information

NPI: 1366612954
Provider Name (Legal Business Name): BAO-THY NGOC GRANT D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 03/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 E CHAPMAN AVE SUITE 100
ORANGE CA
92866-2139
US

IV. Provider business mailing address

1110 E CHAPMAN AVE SUITE 100
ORANGE CA
92866-2139
US

V. Phone/Fax

Practice location:
  • Phone: 714-771-7677
  • Fax: 714-771-1518
Mailing address:
  • Phone: 714-771-7677
  • Fax: 714-771-1518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number52655
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: