Healthcare Provider Details

I. General information

NPI: 1215687538
Provider Name (Legal Business Name): LE-VIET DENTAL AND SURGICAL ARTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7365 CARNELIAN ST STE 111
RANCHO CUCAMONGA CA
91730-1156
US

IV. Provider business mailing address

7365 CARNELIAN ST STE 111
RANCHO CUCAMONGA CA
91730-1156
US

V. Phone/Fax

Practice location:
  • Phone: 909-989-5959
  • Fax:
Mailing address:
  • Phone: 909-989-5959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. NICK LE
Title or Position: OWNER DENTIST / CEO
Credential: DDS
Phone: 415-343-5485