MEDICARE: THU NGUYEN, DDS, INC

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	122300000X	Dentist	019026962	IL

General Provider Information

NPI Number	:	1184052391
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THU NGUYEN, DDS, INC

Provider Business Mailing Address
First Line	:	5324 N ELSTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-1611
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5324 N ELSTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-1611
Country	:	US
Telephone Number	:	773-837-6176
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	THU NGUYEN
Credential	:	DDS
Telephone Number	:	77383776176

Provider Enumeration Date	:	10/25/2013
Last Update Date	:	10/25/2013

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