Healthcare Provider Details

I. General information

NPI: 1962506345
Provider Name (Legal Business Name): KEVIN PHUONG MINH NGUYEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: PHUONG MINH NGUYEN DDS

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 12/09/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1665 W TEVAS AVE
WASKOM TX
75692-6496
US

IV. Provider business mailing address

3147 S CAMINO LAGOS
GRAND PRAIRIE TX
75054-6496
US

V. Phone/Fax

Practice location:
  • Phone: 903-686-1667
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22458
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: