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General NPI Number Information
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NPI Number | 1306112149
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Entity Type | Organization
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Legal Business Name | DENTAL BOAT CLUB P.C
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Dates
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Enumeration Date | 03/27/2012
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Last Update Date | 03/27/2012
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Provider Practice Location Address
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Address Line | 4625 BOAT CLUB RD STE 225
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City | FORT WORTH
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State | TX
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Zip | 76135-7022
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Country | US
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Telephone | 817-666-8110
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Fax |
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Provider Business Mailing Address
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Address Line | 4625 BOAT CLUB RD. SUITE 225
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City | FORT WORTH
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State | TX
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Zip | 75135
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Country | US
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Telephone | 817-666-8110
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. HAIDUONG H NGUYEN
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Credential | DDS
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Telephone | 213-862-0106
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 22593
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License Number State | TX
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