Provider Demographics
NPI:1508876459
Name:NGUYEN, MARK TU (DD S)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:TU
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DD S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7630 N BEACH ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-3018
Mailing Address - Country:US
Mailing Address - Phone:817-605-7272
Mailing Address - Fax:817-605-7270
Practice Address - Street 1:7630 N BEACH ST
Practice Address - Street 2:SUITE 130
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-3018
Practice Address - Country:US
Practice Address - Phone:817-605-7272
Practice Address - Fax:817-605-7270
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX193261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX19326OtherSTATE DENTAL LICENSE