Healthcare Provider Details

I. General information

NPI: 1871083204
Provider Name (Legal Business Name): MY THANH NGUYEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2018
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6529 INGLEWOOD AVE STE A1
STOCKTON CA
95207-3864
US

IV. Provider business mailing address

6529 INGLEWOOD AVE STE A1
STOCKTON CA
95207-3864
US

V. Phone/Fax

Practice location:
  • Phone: 209-473-3788
  • Fax:
Mailing address:
  • Phone: 209-473-3788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDDS104539
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: