=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669698585
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DUC HUU TRUONG DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1775 WASHINGTON ST UNIDENT DENTAL CENTER
-----------------------------------------------------
City | HANOVER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-826-8866
-----------------------------------------------------
Fax | 780-826-1474
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 58 EAST BORDER ROAD
-----------------------------------------------------
City | MALDEN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-325-5353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 18611
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------