Provider Demographics
NPI:1891714754
Name:NGUYEN, PHUNG KIM (DDS)
Entity type:Individual
Prefix:MRS
First Name:PHUNG
Middle Name:KIM
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 1:2114 SENTER
Mailing Address - Street 2:#25
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112
Mailing Address - Country:US
Mailing Address - Phone:408-279-2114
Mailing Address - Fax:408-279-1828
Practice Address - Street 1:2114 SENTER
Practice Address - Street 2:#25
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112
Practice Address - Country:US
Practice Address - Phone:408-279-2114
Practice Address - Fax:408-279-1828
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44749122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA421592283OtherTAX ID
CAB44749-01Medicare ID - Type UnspecifiedMEDICAL PROVIDER