Healthcare Provider Details

I. General information

NPI: 1396744629
Provider Name (Legal Business Name): SUMMIT ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15258 SUMMIT AVE SUITE 300
FONTANA CA
92336-0233
US

IV. Provider business mailing address

15258 SUMMIT AVE SUITE 300
FONTANA CA
92336-0233
US

V. Phone/Fax

Practice location:
  • Phone: 909-646-9600
  • Fax: 909-646-9878
Mailing address:
  • Phone: 909-646-9600
  • Fax: 909-646-9878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number52662
License Number StateCA

VIII. Authorized Official

Name: DR. HENRY MINH NGUYEN
Title or Position: ORTHODONTIST/OWNER
Credential: D.M.D.
Phone: 909-646-9600