Provider Demographics
NPI:1427620160
Name:NGUYEN, MIA THANH (DDS)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:THANH
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 1:1395 22ND ST APT 431
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94107-3965
Mailing Address - Country:US
Mailing Address - Phone:408-772-9337
Mailing Address - Fax:
Practice Address - Street 1:2380 MONUMENT BLVD STE F
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-3972
Practice Address - Country:US
Practice Address - Phone:925-363-4455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1065281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty