MEDICARE: DR. CONG NGUYEN DDS

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	60562186	WA
2	122300000X	Dentist	DN21506	FL

General Provider Information

NPI Number	:	1295117976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CONG NGUYEN DDS

Provider Business Mailing Address
First Line	:	768 CORTARO DR
Second Line	:
City	:	RUSKIN
State	:	FL
Zip	:	33573-6811
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	768 CORTARO DR
Second Line	:
City	:	RUSKIN
State	:	FL
Zip	:	33573-6811
Country	:	US
Telephone Number	:	813-642-8885
Fax Number	:

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

Provider Enumeration Date	:	06/18/2015
Last Update Date	:	10/29/2015

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