Healthcare Provider Details

I. General information

NPI: 1750797445
Provider Name (Legal Business Name): JIMMY NGUYEN D.D.S., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7120 INDIANA AVE SUITE B
RIVERSIDE CA
92504-4562
US

IV. Provider business mailing address

7120 INDIANA AVE SUITE B
RIVERSIDE CA
92504-4562
US

V. Phone/Fax

Practice location:
  • Phone: 951-276-2877
  • Fax: 951-276-1124
Mailing address:
  • Phone: 951-276-2877
  • Fax: 951-276-1124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number57891
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number57891
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number57891
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number57891
License Number StateCA

VIII. Authorized Official

Name: DR. JIMMY NGUYEN
Title or Position: PRESIDENT/DENTIST
Credential:
Phone: 951-276-2877