Healthcare Provider Details

I. General information

NPI: 1902086606
Provider Name (Legal Business Name): SAN JOSE DENTAL SURGERY CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 04/05/2025
Certification Date: 04/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2048 STORY RD
SAN JOSE CA
95122-1668
US

IV. Provider business mailing address

2048 STORY RD
SAN JOSE CA
95122-1668
US

V. Phone/Fax

Practice location:
  • Phone: 408-240-9000
  • Fax:
Mailing address:
  • Phone: 408-240-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberD52747
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD52747
License Number StateCA

VIII. Authorized Official

Name: KHAM NGUYEN
Title or Position: VICE PRESIDENT
Credential: DDS
Phone: 408-240-9000