Provider Demographics
NPI:1629639448
Name:NGUYEN, VAN ANH TERESA
Entity Type:Individual
Prefix:
First Name:VAN ANH
Middle Name:TERESA
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 1:3744 WARWICK BLVD APT 12
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-1480
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2726 EAST HWY 190
Practice Address - Street 2:SUITE 112
Practice Address - City:COPPERAS COVE
Practice Address - State:TX
Practice Address - Zip Code:76522
Practice Address - Country:US
Practice Address - Phone:254-987-6311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35319122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist