Provider Demographics
NPI:1124536859
Name:NGUYEN, TINA A
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:A
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8024 PLEASANT VIEW DR NE
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2113
Mailing Address - Country:US
Mailing Address - Phone:763-742-6537
Mailing Address - Fax:
Practice Address - Street 1:13040 RIVERDALE DR NW STE 600
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-8419
Practice Address - Country:US
Practice Address - Phone:763-323-3042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13919122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist