Provider Demographics
NPI:1578305603
Name:NGO, VIVIAN VAN THAO (DMD)
Entity type:Individual
Prefix:
First Name:VIVIAN VAN
Middle Name:THAO
Last Name:NGO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 N CAPITOL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95127-2327
Mailing Address - Country:US
Mailing Address - Phone:408-417-5401
Mailing Address - Fax:
Practice Address - Street 1:4615 N 1ST ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-0904
Practice Address - Country:US
Practice Address - Phone:800-492-4227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1101411223G0001X, 1223D0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health