Provider Demographics
NPI:1184218927
Name:NGUYEN, KATHY HA
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:HA
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 1:771 CHERRY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-3359
Mailing Address - Country:US
Mailing Address - Phone:504-289-4543
Mailing Address - Fax:
Practice Address - Street 1:2964 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:JOHNSBURG
Practice Address - State:IL
Practice Address - Zip Code:60051-5409
Practice Address - Country:US
Practice Address - Phone:815-363-0103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-23
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019033521122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist