Provider Demographics
NPI:1588482210
Name:NGUYEN, JONATHAN (DMD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 SEBASTIAN BLVD STE 180
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-5192
Mailing Address - Country:US
Mailing Address - Phone:772-581-8515
Mailing Address - Fax:
Practice Address - Street 1:1451 SEBASTIAN BLVD STE 180
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-8200
Practice Address - Country:US
Practice Address - Phone:772-581-8515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-01
Last Update Date:2025-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN29662122300000X, 1223P0700X, 1223S0112X, 1223E0200X, 1223X0400X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No1223P0700XDental ProvidersDentistProsthodontics
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223E0200XDental ProvidersDentistEndodontics
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN29662OtherDENTIST LICENSE