=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649394248
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LONG HOANG LE D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1595 GRAND AVE SUITE 105
-----------------------------------------------------
City | SAN MARCOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92078-2450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-295-1750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1219 WHITE SANDS DR
-----------------------------------------------------
City | SAN MARCOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92078-5488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-295-1750
-----------------------------------------------------
Fax | 760-295-1750
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 50632
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------