Provider Demographics
NPI:1083155543
Name:DIANE HAO NGUYEN DDS, P.C.
Entity Type:Organization
Organization Name:DIANE HAO NGUYEN DDS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INCORPORATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:HAO
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-431-9578
Mailing Address - Street 1:2931 PHILLIPS CT
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-3161
Mailing Address - Country:US
Mailing Address - Phone:678-371-9936
Mailing Address - Fax:770-438-2919
Practice Address - Street 1:969 WINDY HILL RD SE
Practice Address - Street 2:SUITE J
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-2040
Practice Address - Country:US
Practice Address - Phone:770-431-9578
Practice Address - Fax:770-438-2919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012312305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000909235AMedicaid