=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912369216
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERAN NG DMD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2016
-----------------------------------------------------
Last Update Date | 03/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 126 GLENDORA AVE
-----------------------------------------------------
City | LA PUENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91744-4712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-269-2526
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15810 GALE AVE 298
-----------------------------------------------------
City | HACIENDA HEIGHTS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91745-1601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SERAN NG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 267-269-2526
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 59434
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------