Provider Demographics
NPI:1104904218
Name:TRAN, TRUNG DINH (DMD)
Entity type:Individual
Prefix:DR
First Name:TRUNG
Middle Name:DINH
Last Name:TRAN
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 1:1141 BROADWAY ST
Mailing Address - Street 2:SUITE #5
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14904-2542
Mailing Address - Country:US
Mailing Address - Phone:607-732-2555
Mailing Address - Fax:607-732-4447
Practice Address - Street 1:1141 BROADWAY ST
Practice Address - Street 2:SUITE #5
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14904-2542
Practice Address - Country:US
Practice Address - Phone:607-732-2555
Practice Address - Fax:607-732-4447
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY487731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02264253Medicaid
NY412112022OtherTAX ID NUMBER