Provider Demographics
NPI:1104995885
Name:MAI, TRANG KHANH (DDS)
Entity type:Individual
Prefix:DR
First Name:TRANG
Middle Name:KHANH
Last Name:MAI
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 1:1637 PORTAGE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46616-1743
Mailing Address - Country:US
Mailing Address - Phone:574-233-8444
Mailing Address - Fax:574-233-8366
Practice Address - Street 1:1637 PORTAGE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46616-1743
Practice Address - Country:US
Practice Address - Phone:574-233-8444
Practice Address - Fax:574-233-8366
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010453A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice