Provider Demographics
NPI:1619258969
Name:DO NGUYEN, HOLLY (DMD)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:
Last Name:DO NGUYEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 E HAGERT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-1601
Mailing Address - Country:US
Mailing Address - Phone:215-327-6048
Mailing Address - Fax:
Practice Address - Street 1:6404 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-2943
Practice Address - Country:US
Practice Address - Phone:215-743-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0386731223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice