MEDICARE: PHUONG TRAN

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	1223G0001X	General Practice Dentistry	7073	OK
2	122300000X	Dentist	7073	OK

General Provider Information

NPI Number	:	1194203166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHUONG TRAN

Provider Business Mailing Address
First Line	:	6712 NW 112TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162-2978
Country	:	US
Telephone Number	:	405-887-3267
Fax Number	:

Provider Business Practice Location Address
First Line	:	7223 MISSISSIPPI AVE BLDG 1561
Second Line	:
City	:	FT. POLK
State	:	LA
Zip	:	71459-5110
Country	:	US
Telephone Number	:	337-531-2327
Fax Number	:

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

Provider Enumeration Date	:	08/01/2018
Last Update Date	:	04/04/2023

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Directions to “ PHUONG TRAN ” Practice Location

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