=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124409313
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAWN NGUYEN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2015
-----------------------------------------------------
Last Update Date | 06/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27600 HOOVER RD STE 1
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48093-7721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-755-5388
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14207 ROCKENBACH ST
-----------------------------------------------------
City | BALDWIN PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91706-2666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-340-5025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2901021524
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------