Provider Demographics
NPI:1679615736
Name:NGUYEN, CAN (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:CAN
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 WASHINGTON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-3627
Mailing Address - Country:US
Mailing Address - Phone:159-996-9692
Mailing Address - Fax:
Practice Address - Street 1:1200 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-3618
Practice Address - Country:US
Practice Address - Phone:215-999-6969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA455941223X0400X
PADS029806L1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103480959Medicaid
CAD45594Medicaid