=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609492834
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVAN TUAN HUYNH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2020
-----------------------------------------------------
Last Update Date | 06/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1401 S 31ST ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19146-3506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-925-2400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2608 COLLINS ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19125-1408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-342-2938
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | DH071570
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------