Healthcare Provider Details

I. General information

NPI: 1033778212
Provider Name (Legal Business Name): DON LE NGUYENDAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG. 4250 CLEAR CREEK ROAD SUITE 213
FORT HOOD TX
76544
US

IV. Provider business mailing address

4071 LEE RD STE 260
CLEVELAND OH
44128-2173
US

V. Phone/Fax

Practice location:
  • Phone: 254-285-2014
  • Fax: 254-285-2182
Mailing address:
  • Phone: 216-727-0234
  • Fax: 440-381-8800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberRES.004093
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number36128
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: