Provider Demographics
NPI:1336202290
Name:NGUYEN, SI TAN SR (DDS)
Entity type:Individual
Prefix:MR
First Name:SI
Middle Name:TAN
Last Name:NGUYEN
Suffix:SR
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 1:9211 BOLSA AVE
Mailing Address - Street 2:#210
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-5570
Mailing Address - Country:US
Mailing Address - Phone:714-893-1010
Mailing Address - Fax:714-893-0806
Practice Address - Street 1:9211 BOLSA AVE
Practice Address - Street 2:#210
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-5570
Practice Address - Country:US
Practice Address - Phone:714-893-1010
Practice Address - Fax:714-893-0806
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30262122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist