Provider Demographics
NPI:1396252045
Name:NGUYEN, KENNETH CONG (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:CONG
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:KENNY
Other - Middle Name:CONG
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 2283
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-1783
Mailing Address - Country:US
Mailing Address - Phone:626-759-6517
Mailing Address - Fax:
Practice Address - Street 1:12132 BROOKHURST ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-2817
Practice Address - Country:US
Practice Address - Phone:714-638-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-03
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34600122300000X
CA102236122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist