=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184851123
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHONG T NGUYEN D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2009
-----------------------------------------------------
Last Update Date | 06/26/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10901 GARLAND RD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75218-2613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-458-4494
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2737 N FITZHUGH AVE APT 3344
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75204-3397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-458-4494
-----------------------------------------------------
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 | 24553
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------