Provider Demographics
NPI:1417490996
Name:NGUYEN, JONATHAN (DDS)
Entity Type:Individual
Prefix:
First Name:JONATHAN
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 1:490 N CHANDLER RANCH RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-4504
Mailing Address - Country:US
Mailing Address - Phone:714-333-8288
Mailing Address - Fax:
Practice Address - Street 1:13112 NEWPORT AVE STE I
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3440
Practice Address - Country:US
Practice Address - Phone:714-734-8889
Practice Address - Fax:714-734-8887
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-30
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43212122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist