Provider Demographics
NPI:1700234739
Name:NGUYEN, KHIEM DINH
Entity Type:Individual
Prefix:
First Name:KHIEM
Middle Name:DINH
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 WILLARD ST APT 402
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-7480
Mailing Address - Country:US
Mailing Address - Phone:571-262-1693
Mailing Address - Fax:
Practice Address - Street 1:673 ROBESON ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-5425
Practice Address - Country:US
Practice Address - Phone:508-676-8268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401415090122300000X
MADN1857355122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist