Provider Demographics
NPI:1306512975
Name:ETHAN TRUONG DDS OF LEAGUE CITY PLLC
Entity type:Organization
Organization Name:ETHAN TRUONG DDS OF LEAGUE CITY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:678-200-6508
Mailing Address - Street 1:1901 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-4242
Mailing Address - Country:US
Mailing Address - Phone:678-200-6508
Mailing Address - Fax:
Practice Address - Street 1:1901 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-4242
Practice Address - Country:US
Practice Address - Phone:678-200-6508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-23
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty