Provider Demographics
NPI:1871897389
Name:AN NGUYEN DDS PROF CORP
Entity type:Organization
Organization Name:AN NGUYEN DDS PROF CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:AN
Authorized Official - Middle Name:V
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-865-0544
Mailing Address - Street 1:73666 JOSHUA DR.
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277
Mailing Address - Country:US
Mailing Address - Phone:760-865-0544
Mailing Address - Fax:888-877-5510
Practice Address - Street 1:73666 JOSHUA DR.
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277
Practice Address - Country:US
Practice Address - Phone:760-865-0544
Practice Address - Fax:888-877-5510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-28
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA567311223G0001X
CA596411223G0001X
CA575001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1104963750OtherINDIVIDUAL DENTAL PROVIDERS
CA1780801969OtherINDIVIDUAL DENTAL PROVIDER
CA1942538160OtherINDIVIDUAL DENTAL PROVIDER