Provider Demographics
NPI:1801532494
Name:TRAN, TRA PHAM THANH (DDS)
Entity type:Individual
Prefix:MISS
First Name:TRA
Middle Name:PHAM THANH
Last Name:TRAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12602 SHELLEY DR APT 9
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-4933
Mailing Address - Country:US
Mailing Address - Phone:714-234-4351
Mailing Address - Fax:
Practice Address - Street 1:68 STAFFORD ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01603-1450
Practice Address - Country:US
Practice Address - Phone:508-770-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-07
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN18595851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program