Healthcare Provider Details

I. General information

NPI: 1124763826
Provider Name (Legal Business Name): TOM HIEU NGUYEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2022
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 LAS VEGAS BLVD N
NELLIS AFB NV
89191-6600
US

IV. Provider business mailing address

4700 LAS VEGAS BLVD N
NELLIS AFB NV
89191-6600
US

V. Phone/Fax

Practice location:
  • Phone: 702-653-2273
  • Fax:
Mailing address:
  • Phone: 702-653-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number38763
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number38763
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number38763
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: