Provider Demographics
NPI:1528509510
Name:NGUYEN, PHONG (ADT)
Entity type:Individual
Prefix:
First Name:PHONG
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 E FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-2923
Mailing Address - Country:US
Mailing Address - Phone:612-872-8086
Mailing Address - Fax:
Practice Address - Street 1:1213 E FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404
Practice Address - Country:US
Practice Address - Phone:612-872-8086
Practice Address - Fax:612-872-8547
Is Sole Proprietor?:No
Enumeration Date:2017-03-10
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH9909124Q00000X
MNDT78125J00000X, 125K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125K00000XDental ProvidersAdvanced Practice Dental Therapist
No124Q00000XDental ProvidersDental Hygienist
No125J00000XDental ProvidersDental Therapist