Provider Demographics
NPI:1720829286
Name:LE, KHANG PHAN VINH (DDS)
Entity type:Individual
Prefix:
First Name:KHANG
Middle Name:PHAN VINH
Last Name:LE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:600 TECHNOLOGY PARK STE 101
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-7122
Mailing Address - Country:US
Mailing Address - Phone:407-543-8514
Mailing Address - Fax:
Practice Address - Street 1:1985 EASTWEST PKWY
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-8017
Practice Address - Country:US
Practice Address - Phone:904-639-6091
Practice Address - Fax:904-278-5233
Is Sole Proprietor?:No
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLDN289971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice