Healthcare Provider Details

I. General information

NPI: 1811050917
Provider Name (Legal Business Name): PHUONG HELENE TA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 05/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36800 WINFIELD CT
GRAND ISLAND FL
32735-9131
US

IV. Provider business mailing address

1503 BUENOS AIRES BLVD STE 125
LADY LAKE FL
32159-6826
US

V. Phone/Fax

Practice location:
  • Phone: 352-255-5538
  • Fax:
Mailing address:
  • Phone: 352-753-5838
  • Fax: 352-391-5837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN14668
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: