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General NPI Number Information
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NPI Number | 1255590592
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Entity Type | Individual
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Provider Name | BRUCE LONG-TAN PHUNG D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 06/02/2008
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Last Update Date | 06/02/2008
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Provider Practice Location Address
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Address Line | 3817 GRAND AVE SUITE D
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City | CHINO
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State | CA
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Zip | 91710-5443
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Country | US
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Telephone | 909-613-1970
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Fax | 909-613-1972
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Provider Business Mailing Address
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Address Line | 3817 GRAND AVE SUITE D
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City | CHINO
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State | CA
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Zip | 91710-5443
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Country | US
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Telephone | 909-613-1970
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Fax | 909-613-1972
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 47548
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License Number State | CA
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