Provider Demographics
NPI:1093854101
Name:NGUYEN, CHAN KIM (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHAN
Middle Name:KIM
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3531 EL CAJON BLVD #A
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104
Mailing Address - Country:US
Mailing Address - Phone:619-584-8975
Mailing Address - Fax:619-584-0682
Practice Address - Street 1:3531 EL CAJON BLVD #A
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104
Practice Address - Country:US
Practice Address - Phone:619-584-8975
Practice Address - Fax:619-584-0682
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA289651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice