=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538261276
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TUAN M NGUYEN DDS PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 473 ENCINITAS BLVD
-----------------------------------------------------
City | ENACINITAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-634-2024
-----------------------------------------------------
Fax | 760-634-7970
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 473 ENCINITAS BLVD
-----------------------------------------------------
City | ENACINITAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-634-2024
-----------------------------------------------------
Fax | 760-634-7970
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPOUSE CO OWNER SEC OF CORP
-----------------------------------------------------
Name | MRS. CATHLEEN A DOMINGO-NGUYEN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 760-634-2024
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | CA43333
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | CA42750
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------