MEDICARE: LISA 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	1223G0001X	General Practice Dentistry	47534	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G9384201	OTHER	CA	DENTICAL PROVIDER NUMBER

General Provider Information

NPI Number	:	1588717383
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISA NGUYEN DDS INC

Provider Business Mailing Address
First Line	:	2511 S CENTRAL AVE
Second Line	:	SUITE A
City	:	LOS ANGELES
State	:	CA
Zip	:	90011-1634
Country	:	US
Telephone Number	:	213-763-2510
Fax Number	:	213-763-2513

Provider Business Practice Location Address
First Line	:	2511 S CENTRAL AVE
Second Line	:	SUITE A
City	:	LOS ANGELES
State	:	CA
Zip	:	90011-1634
Country	:	US
Telephone Number	:	213-763-2510
Fax Number	:	213-763-2513

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LISA NGUYEN
Credential	:
Telephone Number	:	213-763-2510

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	08/22/2020

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