Basic Information
| Provider Information | |||||||||
| NPI: | 1215016019 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LE | ||||||||
| FirstName: | NGHIEM | ||||||||
| MiddleName: | THANH | ||||||||
| NamePrefix: | PROF. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24749 FAY AVE | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925514045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512474959 | ||||||||
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| Practice Location | |||||||||
| Address1: | CORNER OF ROUTE N21 AND N7 | ||||||||
| Address2: | FORT DEFIANCE INDIAN HOSPITAL BOARD, INC | ||||||||
| City: | FORT DEFIANCE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287298885 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 09/10/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 52417 | CA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 871708 | 05 | AZ | MEDICAID | 55071384 | 05 | NM | MEDICAID |