Healthcare Provider Details

I. General information

NPI: 1225385297
Provider Name (Legal Business Name): JASON THAI CAO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2012
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9211 BOLSA AVE STE 210
WESTMINSTER CA
92683-5570
US

IV. Provider business mailing address

9211 BOLSA AVE STE 210
WESTMINSTER CA
92683-5570
US

V. Phone/Fax

Practice location:
  • Phone: 714-893-1010
  • Fax:
Mailing address:
  • Phone: 714-893-1010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number61712
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: