=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497972798
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. VONNY NGANTUNG
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2007
-----------------------------------------------------
Last Update Date | 08/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 482 LANCASTER DR NE
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97301-4784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-588-7611
-----------------------------------------------------
Fax | 503-588-7551
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 482 LANCASTER DR NE
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97301-4784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-588-7611
-----------------------------------------------------
Fax | 503-588-7551
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORTHODONTIST
-----------------------------------------------------
Name | DR. VONNY NGANTUNG
-----------------------------------------------------
Credential | D.D.S., M.S.
-----------------------------------------------------
Telephone | 503-588-7611
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | D8294
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------