Healthcare Provider Details

I. General information

NPI: 1164624003
Provider Name (Legal Business Name): VIXIANE SENGSOUVANH, DDS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 12/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7277 LONE PINE DR
RANCHO MURIETA CA
95683-9715
US

IV. Provider business mailing address

PO BOX 1451
RANCHO MURIETA CA
95683-1451
US

V. Phone/Fax

Practice location:
  • Phone: 916-354-2637
  • Fax: 916-354-3270
Mailing address:
  • Phone: 916-354-2637
  • Fax: 916-354-3270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number48994
License Number StateCA

VIII. Authorized Official

Name: VIXIANE SENGSOUVANH
Title or Position: CEO
Credential: DDS
Phone: 916-354-2637