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General NPI Number Information
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NPI Number | 1396531364
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Entity Type | Individual
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Provider Name | JACKSON NGUYEN DMD
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Gender | Male
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Dates
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Enumeration Date | 04/16/2025
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Last Update Date | 08/14/2025
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Provider Practice Location Address
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Address Line | 1259 S WABASH AVE
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City | CHICAGO
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State | IL
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Zip | 60605-2412
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Country | US
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Telephone | 424-212-3905
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Fax |
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Provider Business Mailing Address
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Address Line | 4961 GALLEON XING
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City | DECATUR
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State | GA
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Zip | 30035-3053
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.036312
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License Number State | IL
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