Provider Demographics
NPI:1063906535
Name:NGUYEN, JEREMY (DMD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 AUCKLAND ST APT 102
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02125-1549
Mailing Address - Country:US
Mailing Address - Phone:617-888-2478
Mailing Address - Fax:
Practice Address - Street 1:2285 NORTHAMPTON ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040
Practice Address - Country:US
Practice Address - Phone:413-538-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN1858030122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program