Provider Demographics
NPI:1871742536
Name:LE, QUYNH MONG (DDS)
Entity type:Individual
Prefix:DR
First Name:QUYNH
Middle Name:MONG
Last Name:LE
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 1:15 WALLER ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702-5240
Mailing Address - Country:US
Mailing Address - Phone:512-978-9895
Mailing Address - Fax:512-978-9900
Practice Address - Street 1:15 WALLER ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-5240
Practice Address - Country:US
Practice Address - Phone:512-978-9895
Practice Address - Fax:512-978-9900
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX235311223G0001X, 122300000X
AZ76491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist