Healthcare Provider Details

I. General information

NPI: 1699154963
Provider Name (Legal Business Name): BENJAMIN VUONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2015
Last Update Date: 05/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 CINDY LOU DR
SAN ANTONIO TX
78249-1537
US

IV. Provider business mailing address

106 CINDY LOU DR
SAN ANTONIO TX
78249-1537
US

V. Phone/Fax

Practice location:
  • Phone: 832-755-1179
  • Fax:
Mailing address:
  • Phone: 832-755-1179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30888
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: