MEDICARE: KHA MANH NGUYEN DMD

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	019.028743	IL

General Provider Information

NPI Number	:	1205124641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KHA MANH NGUYEN DMD

Provider Business Mailing Address
First Line	:	5644 W ROOSEVELT RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60644-1576
Country	:	US
Telephone Number	:	773-473-8888
Fax Number	:

Provider Business Practice Location Address
First Line	:	5644 W ROOSEVELT RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60644-1576
Country	:	US
Telephone Number	:	773-473-8888
Fax Number	:

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

Provider Enumeration Date	:	07/19/2011
Last Update Date	:	07/19/2011

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Directions to “ KHA MANH NGUYEN DMD” Practice Location

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