Provider Demographics
NPI:1255610242
Name:SOPHEAP TANG DMD DENTAL CORPORATION
Entity type:Organization
Organization Name:SOPHEAP TANG DMD DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SOPHEAP
Authorized Official - Middle Name:
Authorized Official - Last Name:TANG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:951-789-0200
Mailing Address - Street 1:18876 VAN BUREN BLVD
Mailing Address - Street 2:107
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508
Mailing Address - Country:US
Mailing Address - Phone:951-789-0200
Mailing Address - Fax:951-789-0245
Practice Address - Street 1:18876 VAN BUREN BLVD
Practice Address - Street 2:107
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508
Practice Address - Country:US
Practice Address - Phone:951-789-0200
Practice Address - Fax:951-789-0245
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOPHEAP TANG DMD DENTAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-09
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA578441223G0001X
CA582401223P0221X
CA563931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1255523593Medicaid