=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134614878
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DUY V TRUONG DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2018
-----------------------------------------------------
Last Update Date | 06/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4520 TOWN CENTER PKWY UNIT 103
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32246-8590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-717-0361
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6898 A C SKINNER PKWY UNIT 348
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32256-7930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-608-7884
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN23393
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------