Provider Demographics
NPI:1346274917
Name:NGUYEN, BAOANH (DMD)
Entity Type:Individual
Prefix:DR
First Name:BAOANH
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MIMI
Other - Middle Name:BAOANH
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:4017 N 75TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85033-3728
Mailing Address - Country:US
Mailing Address - Phone:623-907-9334
Mailing Address - Fax:623-474-2876
Practice Address - Street 1:4017 N 75TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-3728
Practice Address - Country:US
Practice Address - Phone:623-907-9334
Practice Address - Fax:623-474-2876
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ59941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1346274917Medicaid