Healthcare Provider Details

I. General information

NPI: 1073158564
Provider Name (Legal Business Name): NGUYEN TABARI DENTAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2019
Last Update Date: 11/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10630 TOWN CENTER DR STE 131
RANCHO CUCAMONGA CA
91730-8600
US

IV. Provider business mailing address

10630 TOWN CENTER DR STE 131
RANCHO CUCAMONGA CA
91730-8600
US

V. Phone/Fax

Practice location:
  • Phone: 909-987-8835
  • Fax: 909-484-3101
Mailing address:
  • Phone: 909-987-8835
  • Fax: 909-484-3101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MYRA WOLFINBARGER
Title or Position: MANAGER
Credential:
Phone: 909-987-8835