MEDICARE: QUYEN THUC DUONG PROFESSIONAL DENTAL CORPORATION

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	42146	CA

General Provider Information

NPI Number	:	1568687721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUYEN THUC DUONG PROFESSIONAL DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	175 S CAPITOL AVE
Second Line	:	SUITE E
City	:	SAN JOSE
State	:	CA
Zip	:	95127-2845
Country	:	US
Telephone Number	:	408-923-3073
Fax Number	:	408-923-3075

Provider Business Practice Location Address
First Line	:	175 S CAPITOL AVE
Second Line	:	SUITE E
City	:	SAN JOSE
State	:	CA
Zip	:	95127-2845
Country	:	US
Telephone Number	:	408-923-3073
Fax Number	:	408-923-3075

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. QUYEN THUC DUONG
Credential	:	DDS
Telephone Number	:	408-923-3073

Provider Enumeration Date	:	04/14/2007
Last Update Date	:	05/28/2020

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