Provider Demographics
NPI:1750440533
Name:BUI, PHONG
Entity type:Individual
Prefix:
First Name:PHONG
Middle Name:
Last Name:BUI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 NE 129TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-3264
Mailing Address - Country:US
Mailing Address - Phone:360-574-4574
Mailing Address - Fax:
Practice Address - Street 1:2101 NE 129TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-3264
Practice Address - Country:US
Practice Address - Phone:360-574-4574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000088131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice