Healthcare Provider Details

I. General information

NPI: 1265870042
Provider Name (Legal Business Name): SON THANH NGUYEN RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2013
Last Update Date: 06/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11421 SE NICHOLAS CT
PORTLAND OR
97266-3386
US

IV. Provider business mailing address

11421 SE NICHOLAS CT
PORTLAND OR
97266-3386
US

V. Phone/Fax

Practice location:
  • Phone: 503-734-8103
  • Fax:
Mailing address:
  • Phone: 503-734-8103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH6242
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: