MEDICARE: DR. QUYEN THUC DUONG D.D.S.

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	515878	OTHER	CA	MEDI-CAL PIN

General Provider Information

NPI Number	:	1699948398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. QUYEN THUC DUONG D.D.S.

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2008
Last Update Date	:	04/02/2008

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