=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992088934
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THANH T TRAN D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2011
-----------------------------------------------------
Last Update Date | 09/26/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 709 CENTER DR SUITE 101
-----------------------------------------------------
City | SAN MARCOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92069-2502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-746-2045
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10365 CAMINITO GOMA
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92131-1628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-353-2182
-----------------------------------------------------
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 | 59474
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------