MEDICARE: DR. RANDY TRUNG-QUY 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	B43828	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B43828	OTHER	CA	DENTI-CAL PROVIDER NUMBER

General Provider Information

NPI Number	:	1861552812
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDY TRUNG-QUY NGUYEN D.D.S

Provider Business Mailing Address
First Line	:	3850 MONTGOMERY DR STE C
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-5207
Country	:	US
Telephone Number	:	707-527-8700
Fax Number	:

Provider Business Practice Location Address
First Line	:	3850 MONTGOMERY DR STE C
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-5207
Country	:	US
Telephone Number	:	707-527-8700
Fax Number	:

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

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	07/08/2007

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