Healthcare Provider Details

I. General information

NPI: 1215556766
Provider Name (Legal Business Name): HUONG TRAN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 12/11/2021
Certification Date: 12/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 HAZEL ST
WILLITS CA
95490-4222
US

IV. Provider business mailing address

45 HAZEL ST
WILLITS CA
95490-4222
US

V. Phone/Fax

Practice location:
  • Phone: 707-456-9600
  • Fax:
Mailing address:
  • Phone: 707-456-9600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number106813
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: