MEDICARE: LIEN THIXUAN DANG-PETERSON DDS

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	44665	CA
2	1223G0001X	General Practice Dentistry	44665	CA

General Provider Information

NPI Number	:	1528037421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIEN THIXUAN DANG-PETERSON DDS

Provider Business Mailing Address
First Line	:	751 S BASCOM AVE
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95128-2604
Country	:	US
Telephone Number	:	408-885-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 TULLY RD
Second Line	:	DENTAL CLINIC
City	:	SAN JOSE
State	:	CA
Zip	:	95111-1917
Country	:	US
Telephone Number	:	408-817-1461
Fax Number	:

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

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	12/16/2013

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