=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649395609
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VINH THAT TON DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2007
-----------------------------------------------------
Last Update Date | 02/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2005 KNIGHT LANE BLDG H NAVY MEDICINE SUPPORT COMMAND ATTN: MEDICAL STAF
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32212-0140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-725-7479
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12181 CANDY LN
-----------------------------------------------------
City | GARDEN GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92840-2705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-251-1955
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 21742
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------