MEDICARE: CAPE GIRARDEAU DENTISTRY, LLC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1982232849
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAPE GIRARDEAU DENTISTRY, LLC

Provider Business Mailing Address
First Line	:	2906 BRECKENRIDGE DR
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-1728
Country	:	US
Telephone Number	:	573-334-8798
Fax Number	:	573-334-1370

Provider Business Practice Location Address
First Line	:	2906 BRECKENRIDGE DR
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-1728
Country	:	US
Telephone Number	:	573-334-8798
Fax Number	:	573-334-1370

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DENNIS NGUYEN
Credential	:	DDS
Telephone Number	:	573-334-8798

Provider Enumeration Date	:	03/27/2020
Last Update Date	:	03/27/2020

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