MEDICARE: DR. HAIDUONG H NGUYEN DDS

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	5494	LA
2	1223G0001X	General Practice Dentistry	6828	AZ
3	1223G0001X	General Practice Dentistry	22593	TX
4	1223G0001X	General Practice Dentistry	DN013240	GA

General Provider Information

NPI Number	:	1841339603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HAIDUONG H NGUYEN DDS

Provider Business Mailing Address
First Line	:	4625 BOAT CLUB RD
Second Line	:	SUITE 225
City	:	FORT WORTH
State	:	TX
Zip	:	76135-7022
Country	:	US
Telephone Number	:	817-238-0321
Fax Number	:

Provider Business Practice Location Address
First Line	:	4625 BOAT CLUB RD
Second Line	:	SUITE 225
City	:	FORT WORTH
State	:	TX
Zip	:	76135-7022
Country	:	US
Telephone Number	:	972-444-8888
Fax Number	:

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

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	12/11/2013

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