=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598822769
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. QUYNH TRAM T. TRUONG, DDS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6000 CAMINO REAL
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92509-5362
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-360-0000
-----------------------------------------------------
Fax | 951-616-2036
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6000 CAMINO REAL
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92509-5362
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-360-0000
-----------------------------------------------------
Fax | 951-616-2036
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | QUYNH TRAM TRUONG
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 951-360-0000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 47426
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------