MEDICARE: VIXIANE SENGSOUVANH, DDS, INC.

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	48994	CA

General Provider Information

NPI Number	:	1164624003
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIXIANE SENGSOUVANH, DDS, INC.

Provider Business Mailing Address
First Line	:	PO BOX 1451
Second Line	:
City	:	RANCHO MURIETA
State	:	CA
Zip	:	95683-1451
Country	:	US
Telephone Number	:	916-354-2637
Fax Number	:	916-354-3270

Provider Business Practice Location Address
First Line	:	7277 LONE PINE DR
Second Line	:
City	:	RANCHO MURIETA
State	:	CA
Zip	:	95683-9715
Country	:	US
Telephone Number	:	916-354-2637
Fax Number	:	916-354-3270

Authorized Official
Title or Position	:	CEO
Name	:	VIXIANE SENGSOUVANH
Credential	:	DDS
Telephone Number	:	916-354-2637

Provider Enumeration Date	:	06/04/2007
Last Update Date	:	12/12/2012

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