Provider Demographics
NPI:1104963750
Name:NGUYEN, AN VAN (DDS)
Entity type:Individual
Prefix:
First Name:AN
Middle Name:VAN
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73666 JOSHUA DR
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277-2572
Mailing Address - Country:US
Mailing Address - Phone:760-666-3711
Mailing Address - Fax:760-673-7321
Practice Address - Street 1:73666 JOSHUA DR
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277-2572
Practice Address - Country:US
Practice Address - Phone:760-666-3711
Practice Address - Fax:760-673-7321
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA567311223G0001X
FLDN 17043122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice