Provider Demographics
NPI:1306455654
Name:CAO, TUAN PHUONG (DDS)
Entity type:Individual
Prefix:
First Name:TUAN
Middle Name:PHUONG
Last Name:CAO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4529 SAINT MARY ST
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-2029
Mailing Address - Country:US
Mailing Address - Phone:504-458-1217
Mailing Address - Fax:
Practice Address - Street 1:4641 W DIVERSEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1828
Practice Address - Country:US
Practice Address - Phone:773-692-4147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-23
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7091122300000X
IL019.0338961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist