MEDICARE: THANHTHAO NGUYEN TRAN DMD

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	54524	CA

General Provider Information

NPI Number	:	1518141878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THANHTHAO NGUYEN TRAN DMD

Provider Business Mailing Address
First Line	:	6786 WESTWOOD ST
Second Line	:
City	:	MOORPARK
State	:	CA
Zip	:	93021-1342
Country	:	US
Telephone Number	:	805-298-0541
Fax Number	:

Provider Business Practice Location Address
First Line	:	883 E LOS ANGELES AVE
Second Line	:
City	:	SIMI VALLEY
State	:	CA
Zip	:	93065-1822
Country	:	US
Telephone Number	:	805-520-3567
Fax Number	:	805-669-3224

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

Provider Enumeration Date	:	12/21/2007
Last Update Date	:	12/21/2007

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