=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922770817
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDY P. DUONG DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2021
-----------------------------------------------------
Last Update Date | 09/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4440 SAN PABLO DAM RD STE C
-----------------------------------------------------
City | EL SOBRANTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94803-3052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-223-4311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4440 SAN PABLO DAM RD STE C
-----------------------------------------------------
City | EL SOBRANTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94803-3052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-223-4311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER DENTIST
-----------------------------------------------------
Name | MR. ANDY DUONG
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 415-812-3642
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------