=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982381893
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. LINH NHAT TRAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2023
-----------------------------------------------------
Last Update Date | 07/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3917 SHADY LN
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23188-2554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-847-8319
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3917 SHADY LN
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23188-2554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-847-8319
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019034382
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------