Provider Demographics
NPI:1588353510
Name:NGUYEN, ROBERT
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11559 CAMBRIA CT
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-7229
Mailing Address - Country:US
Mailing Address - Phone:904-422-3245
Mailing Address - Fax:
Practice Address - Street 1:3123 S ORANGE AVE # 107
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-6121
Practice Address - Country:US
Practice Address - Phone:407-392-1521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-04
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0119001223G0001X
390200000X
FLDN297511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program