Provider Demographics
NPI:1497285993
Name:NGUYEN, THI KIM LY
Entity Type:Individual
Prefix:
First Name:THI KIM
Middle Name:LY
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 VILLAGE GRN
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-5479
Mailing Address - Country:US
Mailing Address - Phone:469-531-9479
Mailing Address - Fax:
Practice Address - Street 1:7075 W WHEATLAND RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75249-1067
Practice Address - Country:US
Practice Address - Phone:972-905-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-15
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX329371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice