Provider Demographics
NPI:1376170266
Name:NGUYEN, JENNIFER PHAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:PHAM
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 E CHURCH ST APT 1101
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-3160
Mailing Address - Country:US
Mailing Address - Phone:703-577-2438
Mailing Address - Fax:
Practice Address - Street 1:2180 N COURTENAY PKWY
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4236
Practice Address - Country:US
Practice Address - Phone:321-452-3388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16850122300000X
FL263221223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist