Provider Demographics
NPI:1225187214
Name:NGUYEN, SON VAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SON
Middle Name:VAN
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2065 ROCKBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3513
Mailing Address - Country:US
Mailing Address - Phone:770-469-9771
Mailing Address - Fax:
Practice Address - Street 1:2065 ROCKBRIDGE RD
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3513
Practice Address - Country:US
Practice Address - Phone:770-469-9771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0123431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000926901AMedicaid
GA100237Medicaid
GA108930Medicaid