Provider Demographics
NPI:1447369301
Name:NGUYEN, KHANG T (DMD)
Entity type:Individual
Prefix:DR
First Name:KHANG
Middle Name:T
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3208 E LOS ANGELES AVE
Mailing Address - Street 2:SUITE 33
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-6107
Mailing Address - Country:US
Mailing Address - Phone:805-584-2553
Mailing Address - Fax:805-584-1410
Practice Address - Street 1:3208 E LOS ANGELES AVE
Practice Address - Street 2:SUITE 33
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-6107
Practice Address - Country:US
Practice Address - Phone:805-584-2553
Practice Address - Fax:805-584-1410
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0365891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB36589-01Medicaid