Healthcare Provider Details

I. General information

NPI: 1538633813
Provider Name (Legal Business Name): CUONG PHU NGUYEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2019
Last Update Date: 01/06/2022
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 WESTCHESTER HALL
STONY BROOK NY
11794-0001
US

IV. Provider business mailing address

100 RONKONKOMA AVE APT 5E
RONKONKOMA NY
11779-2792
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-2557
  • Fax:
Mailing address:
  • Phone: 714-232-3543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number2901601178
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: