Provider Demographics
NPI:1154488716
Name:NGUYEN, TRACY V (DDS)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:V
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 W ROBINHOOD DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5507
Mailing Address - Country:US
Mailing Address - Phone:209-956-0880
Mailing Address - Fax:209-956-0883
Practice Address - Street 1:1240 W ROBINHOOD DR
Practice Address - Street 2:SUITE B
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5507
Practice Address - Country:US
Practice Address - Phone:209-956-0880
Practice Address - Fax:209-956-0883
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49168122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB49168OtherDELTA DENTAL HEALTHY FAMI
CAD49168OtherDENTICAL PROVIDER
CA12143OtherPACIFI UNION DENTAL
CAG92904-01OtherDENTI-CAL