Healthcare Provider Details

I. General information

NPI: 1053797456
Provider Name (Legal Business Name): CUONG QUOC NGUYEN DMD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2015
Last Update Date: 03/26/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 N. PACIFIC COAST HWY, SUITE 1150
EL SEGUNDO CA
90245
US

IV. Provider business mailing address

390 N. PACIFIC COAST HWY, SUITE 1150
EL SEGUNDO CA
90245
US

V. Phone/Fax

Practice location:
  • Phone: 310-322-1814
  • Fax: 267-769-1596
Mailing address:
  • Phone: 310-322-1814
  • Fax: 267-597-3622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDS040485
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS103209
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: