Provider Demographics
NPI:1689050296
Name:NGUYEN, ELAINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4784
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92842-4784
Mailing Address - Country:US
Mailing Address - Phone:714-386-2971
Mailing Address - Fax:
Practice Address - Street 1:4060 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1608
Practice Address - Country:US
Practice Address - Phone:619-564-7018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA646531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice