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General NPI Number Information
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NPI Number | 1649406133
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Entity Type | Organization
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Legal Business Name | 1692 TULLY DENTISTRY
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Dates
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Enumeration Date | 06/10/2009
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Last Update Date | 06/10/2009
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Provider Practice Location Address
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Address Line | 2114 SENIOR ROAD SUITE 25
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City | SAN JOSE
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State | CA
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Zip | 95112
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Country | US
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Telephone | 408-279-2114
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Fax | 408-279-1828
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Provider Business Mailing Address
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Address Line | 1692 TULLY ROAD #4
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City | SAN JOSE
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State | CA
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Zip | 95122
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Country | US
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Telephone | 408-223-6953
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Fax | 408-223-0749
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Authorized Official
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Title or Position | DENTIST
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Name | MRS. PHUNG KIM NGUYEN
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Credential |
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Telephone | 408-279-2114
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 44749
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License Number State | CA
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