MEDICARE: DR. AIVAN NGUYEN DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	56276	CA

General Provider Information

NPI Number	:	1174779383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AIVAN NGUYEN DDS

Provider Business Mailing Address
First Line	:	1125 S SAN GABRIEL BLVD
Second Line	:
City	:	SAN GABRIEL
State	:	CA
Zip	:	91776-3114
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1125 S SAN GABRIEL BLVD
Second Line	:
City	:	SAN GABRIEL
State	:	CA
Zip	:	91776-3114
Country	:	US
Telephone Number	:	626-291-2917
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2008
Last Update Date	:	06/16/2016

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