MEDICARE: DR. SELENA 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	DS042856	PA

General Provider Information

NPI Number	:	1578172128
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SELENA NGUYEN DMD

Provider Business Mailing Address
First Line	:	129 LONG LN
Second Line	:
City	:	UPPER DARBY
State	:	PA
Zip	:	19082-3116
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4837 N BROAD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19141-2107
Country	:	US
Telephone Number	:	215-329-9988
Fax Number	:

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

Provider Enumeration Date	:	07/29/2020
Last Update Date	:	07/29/2020

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