Provider Demographics
NPI:1376801076
Name:KHUU, TAN NHAT (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:TAN
Middle Name:NHAT
Last Name:KHUU
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 SIENA
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-7635
Mailing Address - Country:US
Mailing Address - Phone:949-910-5008
Mailing Address - Fax:
Practice Address - Street 1:7725 GATEWAY UNIT 4201
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-1599
Practice Address - Country:US
Practice Address - Phone:910-622-0774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-01
Last Update Date:2024-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1030801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADDS103080OtherSTATE DENTISTRY LICENSE