Healthcare Provider Details

I. General information

NPI: 1902995186
Provider Name (Legal Business Name): HENRY M NGUYEN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 06/26/2010
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:
Title or Position:
Credential:
Phone: