Healthcare Provider Details

I. General information

NPI: 1780163212
Provider Name (Legal Business Name): LAM KHANH VUONG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2018
Last Update Date: 09/04/2020
Certification Date: 09/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

678 N WILSON WAY
STOCKTON CA
95205-4272
US

IV. Provider business mailing address

678 N WILSON WAY
STOCKTON CA
95205-4272
US

V. Phone/Fax

Practice location:
  • Phone: 209-235-0226
  • Fax:
Mailing address:
  • Phone: 209-235-0226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number105433
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: