Healthcare Provider Details

I. General information

NPI: 1902964059
Provider Name (Legal Business Name): PHUONG-LY THI BUI D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

794 SOUTH HARBOR BLVD.
SANTA ANA CA
92704
US

IV. Provider business mailing address

794 SOUTH HARBOR BLVD.
SANTA ANA CA
92704-2339
US

V. Phone/Fax

Practice location:
  • Phone: 714-839-9925
  • Fax:
Mailing address:
  • Phone: 714-839-9925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number42810
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: