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General NPI Number Information
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NPI Number | 1144370768
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Entity Type | Organization
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Legal Business Name | DEREK DUNGQUANG DUONG PROFESSIONAL DENTAL CORP
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Dates
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Enumeration Date | 01/12/2007
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Last Update Date | 12/29/2017
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Provider Practice Location Address
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Address Line | 2263 FAIRVIEW RD STE K
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City | COSTA MESA
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State | CA
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Zip | 92627-1672
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Country | US
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Telephone | 949-515-9280
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Fax | 949-515-9289
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Provider Business Mailing Address
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Address Line | 2263 FAIRVIEW RD STE K
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City | COSTA MESA
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State | CA
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Zip | 92627-1672
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Country | US
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Telephone | 949-515-9280
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Fax | 949-515-9289
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DEREK DUNGQUANG DUONG
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Credential | DMD
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Telephone | 949-515-9280
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 48906
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License Number State | CA
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