Provider Demographics
NPI:1598902967
Name:NGUYEN, KIET TUAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:KIET
Middle Name:TUAN
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 1:9864 KATELLA AVE
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-6418
Mailing Address - Country:US
Mailing Address - Phone:714-636-1112
Mailing Address - Fax:
Practice Address - Street 1:9864 KATELLA AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-6418
Practice Address - Country:US
Practice Address - Phone:714-636-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA491691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB4916901Medicaid