Healthcare Provider Details

I. General information

NPI: 1679615736
Provider Name (Legal Business Name): CAN NGUYEN DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 WASHINGTON AVE
PHILADELPHIA PA
19147-3618
US

IV. Provider business mailing address

1200 WASHINGTON AVE STE 200
PHILADELPHIA PA
19147-3627
US

V. Phone/Fax

Practice location:
  • Phone: 215-999-6969
  • Fax:
Mailing address:
  • Phone: 159-996-9692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number45594
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS029806L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: