Healthcare Provider Details

I. General information

NPI: 1982180493
Provider Name (Legal Business Name): KELLY NGUYEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17781 SANTIAGO BLVD
ORANGE CA
92861-4134
US

IV. Provider business mailing address

803 POLARIS DR
TUSTIN CA
92782-1721
US

V. Phone/Fax

Practice location:
  • Phone: 714-974-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number102371
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: