Healthcare Provider Details

I. General information

NPI: 1306455654
Provider Name (Legal Business Name): TUAN PHUONG CAO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4641 W DIVERSEY AVE
CHICAGO IL
60639-1828
US

IV. Provider business mailing address

4529 SAINT MARY ST
METAIRIE LA
70006-2029
US

V. Phone/Fax

Practice location:
  • Phone: 773-692-4147
  • Fax:
Mailing address:
  • Phone: 504-458-1217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number7091
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.033896
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: