MEDICARE: DR. DOMINIC DUY NGUYEN DMD

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	1223G0001X	General Practice Dentistry	DN1858471	MA

General Provider Information

NPI Number	:	1194370700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOMINIC DUY NGUYEN DMD

Provider Business Mailing Address
First Line	:	427 MAIN ST
Second Line	:
City	:	MALDEN
State	:	MA
Zip	:	02148-5012
Country	:	US
Telephone Number	:	781-322-5070
Fax Number	:	781-322-5073

Provider Business Practice Location Address
First Line	:	427 MAIN ST
Second Line	:
City	:	MALDEN
State	:	MA
Zip	:	02148-5012
Country	:	US
Telephone Number	:	781-322-5070
Fax Number	:	781-322-5073

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

Provider Enumeration Date	:	08/09/2019
Last Update Date	:	09/01/2020

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