Provider Demographics
NPI:1295203941
Name:DR. JACQUELINE B. NGUYEN, DDS, APC
Entity Type:Organization
Organization Name:DR. JACQUELINE B. NGUYEN, DDS, APC
Other - Org Name:EVERGREEN DENTISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:B
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:408-472-4749
Mailing Address - Street 1:2847 S WHITE RD STE 204
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-2942
Mailing Address - Country:US
Mailing Address - Phone:408-238-8380
Mailing Address - Fax:408-238-8404
Practice Address - Street 1:2847 S WHITE RD STE 204
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95148-2942
Practice Address - Country:US
Practice Address - Phone:408-238-8380
Practice Address - Fax:408-238-8404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-09
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA48969OtherDENTAL LICENSE