Provider Demographics
NPI:1598171993
Name:JIMMY NGUYEN D.D.S., INC
Entity Type:Organization
Organization Name:JIMMY NGUYEN D.D.S., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-890-9398
Mailing Address - Street 1:1918 BUSINESS CENTER DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3439
Mailing Address - Country:US
Mailing Address - Phone:909-890-9398
Mailing Address - Fax:
Practice Address - Street 1:1918 BUSINESS CENTER DR
Practice Address - Street 2:SUITE 210
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3439
Practice Address - Country:US
Practice Address - Phone:909-890-9398
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57891302F00000X
CA57981302R00000X, 305R00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No302F00000XManaged Care OrganizationsExclusive Provider Organization
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305S00000XManaged Care OrganizationsPoint of Service