Healthcare Provider Details

I. General information

NPI: 1558943159
Provider Name (Legal Business Name): DINH KHOA NGUYEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date: 09/07/2025
Reactivation Date: 12/09/2025

III. Provider practice location address

1110 N DUTTON AVE
SANTA ROSA CA
95401-4606
US

IV. Provider business mailing address

1110 N DUTTON AVE
SANTA ROSA CA
95401-4606
US

V. Phone/Fax

Practice location:
  • Phone: 707-303-3395
  • Fax: 707-303-3181
Mailing address:
  • Phone: 707-303-3395
  • Fax: 707-303-3181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number112256
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: