=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043629827
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIEP H. LE, DDS. DENTAL CORP II
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2014
-----------------------------------------------------
Last Update Date | 08/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 195 MERIDIAN ST A-5
-----------------------------------------------------
City | HOLLISTER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95023-2221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-630-5720
-----------------------------------------------------
Fax | 831-630-5721
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 195 MERIDIAN ST A-5
-----------------------------------------------------
City | HOLLISTER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95023-2221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-630-5720
-----------------------------------------------------
Fax | 831-630-5721
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. DIEP HONG LE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 830-630-5720
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 43033
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------