Provider Demographics
NPI:1578293957
Name:NGUYEN, KEVIN (DMD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20000 N 57TH AVE RM Q209
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7253
Mailing Address - Country:US
Mailing Address - Phone:310-634-2646
Mailing Address - Fax:
Practice Address - Street 1:753 N MCQUEEN RD
Practice Address - Street 2:STE 102-103
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233
Practice Address - Country:US
Practice Address - Phone:972-361-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-16
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38460122300000X
AZD011450122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist