Healthcare Provider Details

I. General information

NPI: 1295025880
Provider Name (Legal Business Name): DUY QUOC NGUYEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2011
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 WILFORD HALL LOOP
JBSA LACKLAND AFB TX
78236
US

IV. Provider business mailing address

1100 WILFORD HALL LOOP
JBSA LACKLAND TX
78236-5638
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-8626
  • Fax:
Mailing address:
  • Phone: 210-292-8626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number60648
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number39849
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number11407513-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: