=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083006266
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEANNE NGUYEN, DDS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2015
-----------------------------------------------------
Last Update Date | 02/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29941 AVENTURA STE C
-----------------------------------------------------
City | RANCHO SANTA MARGARITA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92688-2015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-858-5150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29941 AVENTURA STE C
-----------------------------------------------------
City | RANCHO SANTA MARGARITA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92688-2015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-858-5150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. JEANNE THI NGUYEN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 949-858-5150
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 59162
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------