=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972003432
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIMOTHY NGUYEN DMD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2018
-----------------------------------------------------
Last Update Date | 02/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4709 W PARKER RD STE 515
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-3382
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-985-0005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4709 W PARKER RD STE 515
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-3382
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-985-0005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. TIMOTHY NGUYEN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 214-535-5572
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 31342
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------