MEDICARE: DR. PAULINE PHUONG NGUYEN D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	47143	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B47143-01	OTHER	CA	DELTA DENTAL STATE GOV PR
2	G92526-01	OTHER	CA	DENTI-CAL

General Provider Information

NPI Number	:	1053319707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAULINE PHUONG NGUYEN D.D.S.

Provider Business Mailing Address
First Line	:	5278 MONTEREY HWY
Second Line	:	SUITE 10
City	:	SAN JOSE
State	:	CA
Zip	:	95111-4268
Country	:	US
Telephone Number	:	408-362-9622
Fax Number	:	408-362-9633

Provider Business Practice Location Address
First Line	:	5278 MONTEREY HWY
Second Line	:	SUITE 10
City	:	SAN JOSE
State	:	CA
Zip	:	95111-4268
Country	:	US
Telephone Number	:	408-362-9622
Fax Number	:	408-362-9633

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	07/13/2016

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