Provider Demographics
NPI:1225191968
Name:NGUYEN, NAM-RENE (DDS)
Entity Type:Individual
Prefix:
First Name:NAM-RENE
Middle Name:
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 1:320 E WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-2348
Mailing Address - Country:US
Mailing Address - Phone:623-932-3344
Mailing Address - Fax:623-932-0594
Practice Address - Street 1:320 E WESTERN AVE
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-2348
Practice Address - Country:US
Practice Address - Phone:623-932-3344
Practice Address - Fax:623-932-0594
Is Sole Proprietor?:No
Enumeration Date:2006-12-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ50741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ480476Medicaid