Healthcare Provider Details

I. General information

NPI: 1811273428
Provider Name (Legal Business Name): LONG NGOC PHUNG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2011
Last Update Date: 03/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30571 TEMECULA PKWY
TEMECULA CA
92592-4821
US

IV. Provider business mailing address

32021 CAMPANULA WAY APT 13103
TEMECULA CA
92592-8573
US

V. Phone/Fax

Practice location:
  • Phone: 310-940-6471
  • Fax:
Mailing address:
  • Phone: 310-940-6471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number60607
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number27527
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: