Provider Demographics
NPI:1194818476
Name:THAI, QUYNH-THU (DDS)
Entity type:Individual
Prefix:
First Name:QUYNH-THU
Middle Name:
Last Name:THAI
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 1:855 S MAIN AVE
Mailing Address - Street 2:SUITE J
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92028-3351
Mailing Address - Country:US
Mailing Address - Phone:760-723-8599
Mailing Address - Fax:760-723-6289
Practice Address - Street 1:855 S MAIN AVE
Practice Address - Street 2:SUITE J
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-3351
Practice Address - Country:US
Practice Address - Phone:760-723-8599
Practice Address - Fax:760-723-6289
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA373721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93329-01Medicaid