Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 31952 | CA |
NPI | 1033678487 |
---|---|
Provider Name | Quoc-Hiep Phan Dao |
First Address | Garden Grove, CA 92843-3230 |
Second Address | Garden Grove, CA 92843-3230 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/03/2019 |
Last Update Date | 15/03/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
31952 | DENTAL HYGIENE (01) | CA |