Healthcare Provider Details

I. General information

NPI: 1639517394
Provider Name (Legal Business Name): KHUONG NGUYEN, DDS A PROFESSIONAL DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2013
Last Update Date: 06/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2780 CARDINAL RD STE A
SAN DIEGO CA
92123-3354
US

IV. Provider business mailing address

2780 CARDINAL RD STE A
SAN DIEGO CA
92123-3354
US

V. Phone/Fax

Practice location:
  • Phone: 858-650-0838
  • Fax: 858-650-0836
Mailing address:
  • Phone: 858-650-0838
  • Fax: 858-650-0836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number44965
License Number StateCA

VIII. Authorized Official

Name: DR. KHUONG HUU NGUYEN
Title or Position: OWNER
Credential: D.D.S
Phone: 858-650-0838