Healthcare Provider Details

I. General information

NPI: 1295733293
Provider Name (Legal Business Name): THAO NGUYEN D.M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12751 SW 2ND ST
BEAVERTON OR
97005-2708
US

IV. Provider business mailing address

12751 SW 2ND ST
BEAVERTON OR
97005-2708
US

V. Phone/Fax

Practice location:
  • Phone: 503-644-3312
  • Fax: 503-644-1713
Mailing address:
  • Phone: 503-644-3312
  • Fax: 503-644-1713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD7199
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: