MEDICARE: BAO TRUC SYBO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	23587	FL
2	122300000X	Dentist	11157	TN

General Provider Information

NPI Number	:	1013574284
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BAO TRUC SYBO

Provider Business Mailing Address
First Line	:	1400 ROSA L PARKS BLVD APT 217
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37208-2571
Country	:	US
Telephone Number	:	504-723-4028
Fax Number	:

Provider Business Practice Location Address
First Line	:	4502 CHARLOTTE PIKE
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37209
Country	:	US
Telephone Number	:	615-933-1981
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2019
Last Update Date	:	09/27/2019

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Directions to “ BAO TRUC SYBO ” Practice Location

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