Provider Demographics
NPI:1568033579
Name:NGUYEN, JESSICA THIEN KIM
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:THIEN KIM
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 1:2912 MEADOW HAWK WAY
Mailing Address - Street 2:
Mailing Address - City:ANTELOPE
Mailing Address - State:CA
Mailing Address - Zip Code:95843-4032
Mailing Address - Country:US
Mailing Address - Phone:408-831-8197
Mailing Address - Fax:
Practice Address - Street 1:1259 PLEASANT GROVE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-6974
Practice Address - Country:US
Practice Address - Phone:916-782-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS106416122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist