MEDICARE: KHANH P NGUYEN D.D.S.

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	1223G0001X	General Practice Dentistry		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215149851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KHANH P NGUYEN D.D.S.

Provider Business Mailing Address
First Line	:	212 E CULLERTON ST APT 712
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-1293
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4614 S KEDZIE AVE
Second Line	:	2020 N. CALIFORNIA AVE UNIT 5
City	:	CHICAGO
State	:	IL
Zip	:	60632-2945
Country	:	US
Telephone Number	:	773-772-8001
Fax Number	:

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

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	07/08/2007

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