MEDICARE: ERIQ NGUYEN DDS DENTAL CORPORATION

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	57276	CA

General Provider Information

NPI Number	:	1780110593
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ERIQ NGUYEN DDS DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	33 CREEK RD STE 350
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92604-7708
Country	:	US
Telephone Number	:	949-689-6502
Fax Number	:

Provider Business Practice Location Address
First Line	:	33 CREEK RD STE 350
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92604-7708
Country	:	US
Telephone Number	:	949-689-6502
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ERIQ NGUYEN
Credential	:
Telephone Number	:	949-689-6502

Provider Enumeration Date	:	05/11/2017
Last Update Date	:	05/11/2017

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