Provider Demographics
NPI:1588022065
Name:NGUYEN, MARILYN MAIA
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:MAIA
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 1:15642 SAND CANYON AVE PO BOX 51443
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92619
Mailing Address - Country:US
Mailing Address - Phone:415-857-4062
Mailing Address - Fax:
Practice Address - Street 1:16475 SIERRA LAKES PKWY STE 140
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1259
Practice Address - Country:US
Practice Address - Phone:909-357-0869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-29
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101758122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice