Healthcare Provider Details

I. General information

NPI: 1669901518
Provider Name (Legal Business Name): LONG HOANG KIM CAO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2017
Last Update Date: 08/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 MIRANDA AVE
PALO ALTO CA
94304
US

IV. Provider business mailing address

1350 E MAIN ST
GRASS VALLEY CA
95945-5208
US

V. Phone/Fax

Practice location:
  • Phone: 253-353-4613
  • Fax:
Mailing address:
  • Phone: 253-353-4613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number103038
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: