Healthcare Provider Details

I. General information

NPI: 1043566813
Provider Name (Legal Business Name): MICHAEL NGUYEN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2012
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 SENTER RD
SAN JOSE CA
95111-3616
US

IV. Provider business mailing address

60 SENTER RD
SAN JOSE CA
95111-3616
US

V. Phone/Fax

Practice location:
  • Phone: 408-483-3568
  • Fax:
Mailing address:
  • Phone: 408-483-3568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number60044
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: