Provider Demographics
NPI:1114219615
Name:NGUYEN, DEREK P (DDS)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:P
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 1:11228 NE 134TH PL
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-2070
Mailing Address - Country:US
Mailing Address - Phone:360-921-2187
Mailing Address - Fax:
Practice Address - Street 1:8016 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-9692
Practice Address - Country:US
Practice Address - Phone:315-637-6961
Practice Address - Fax:315-637-0169
Is Sole Proprietor?:No
Enumeration Date:2011-05-03
Last Update Date:2019-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0563061223P0221X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes1223P0221XDental ProvidersDentistPediatric Dentistry