Healthcare Provider Details

I. General information

NPI: 1447958566
Provider Name (Legal Business Name): KELLY NGOC NGUYEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2023
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 MARIETTA BLVD NW STE 300
ATLANTA GA
30318-2260
US

IV. Provider business mailing address

1881 SECOND AVE APT 2509
DECATUR GA
30032-4440
US

V. Phone/Fax

Practice location:
  • Phone: 346-273-5829
  • Fax:
Mailing address:
  • Phone: 346-273-5829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN124194
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: