=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093232639
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHUONG THIBICH NGUYEN DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2017
-----------------------------------------------------
Last Update Date | 08/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 N TIMBERLAND DR
-----------------------------------------------------
City | LUFKIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75901-0460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-465-9314
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7817 COOK RD
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77072-3212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-335-6695
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 33440
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------