Provider Demographics
NPI:1144874470
Name:TRUONG, BAO (DMD)
Entity type:Individual
Prefix:
First Name:BAO
Middle Name:
Last Name:TRUONG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1738 165TH ST
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46320-2814
Mailing Address - Country:US
Mailing Address - Phone:219-844-8000
Mailing Address - Fax:
Practice Address - Street 1:1738 165TH ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46320-2814
Practice Address - Country:US
Practice Address - Phone:219-844-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-25
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032259122300000X
IN12013784A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist