=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225889975
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL PHAN NGUYEN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2024
-----------------------------------------------------
Last Update Date | 07/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13180 SE 172ND AVE STE 146
-----------------------------------------------------
City | HAPPY VALLEY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97086-9654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-353-6568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13376 SE SCENIC RIDGE DR
-----------------------------------------------------
City | CLACKAMAS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97015-7534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-454-1999
-----------------------------------------------------
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 | 12018
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------