Healthcare Provider Details

I. General information

NPI: 1932474186
Provider Name (Legal Business Name): THU THANH TRUONG D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 03/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 HALE AVENUE
NEWMAN GROVE NE
68758-0045
US

IV. Provider business mailing address

P.O. BOX 45 412 HALE AVENUE
NEWMAN GROVE NE
68758-0045
US

V. Phone/Fax

Practice location:
  • Phone: 402-447-6469
  • Fax: 402-447-6098
Mailing address:
  • Phone: 402-447-6469
  • Fax: 402-447-6098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5593
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberM900
License Number StateSD
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number37614
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: