Healthcare Provider Details

I. General information

NPI: 1073787321
Provider Name (Legal Business Name): PHUOC THANH VUONG DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2008
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 E PLEASANT ST
MILWAUKEE WI
53212-3532
US

IV. Provider business mailing address

538 CONSERVATORY LN
AURORA IL
60502-8913
US

V. Phone/Fax

Practice location:
  • Phone: 414-435-5850
  • Fax:
Mailing address:
  • Phone: 630-862-5169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.025958
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6861-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: