Healthcare Provider Details

I. General information

NPI: 1588042071
Provider Name (Legal Business Name): DR. THOMAS NGUYEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2015
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LA GOMA ST
MILL VALLEY CA
94941-2875
US

IV. Provider business mailing address

1187 DUZMAL AVE
SAN LEANDRO CA
94579-2354
US

V. Phone/Fax

Practice location:
  • Phone: 415-924-6551
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number100563
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: