=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902348717
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEAN NGUYEN, DDS INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2016
-----------------------------------------------------
Last Update Date | 11/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23642 ROCKFIELD BLVD STE 504
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92630-1681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-415-7776
-----------------------------------------------------
Fax | 949-916-9906
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23642 ROCKFIELD BLVD STE 504
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92630-1681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-415-7776
-----------------------------------------------------
Fax | 949-916-9906
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SEAN NGUYEN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 949-415-7776
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 58399
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------