Healthcare Provider Details

I. General information

NPI: 1255408456
Provider Name (Legal Business Name): VINH TU VUONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 GORDON HWY #22
AUGUSTA GA
30906-2292
US

IV. Provider business mailing address

415 N GRAND AVE
PUEBLO CO
81003-3111
US

V. Phone/Fax

Practice location:
  • Phone: 706-790-9302
  • Fax:
Mailing address:
  • Phone: 719-583-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN013451
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: