MEDICARE: DR. KEN TRUONG 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	1223G0001X	General Practice Dentistry	DDS103366	CA

General Provider Information

NPI Number	:	1639648454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEN TRUONG DMD

Provider Business Mailing Address
First Line	:	4236 EL CAJON BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92105-1230
Country	:	US
Telephone Number	:	619-584-4015
Fax Number	:

Provider Business Practice Location Address
First Line	:	4236 EL CAJON BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92105-1230
Country	:	US
Telephone Number	:	619-584-4015
Fax Number	:	619-584-4016

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

Provider Enumeration Date	:	11/21/2018
Last Update Date	:	10/03/2019

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