Provider Demographics
NPI:1710069372
Name:NGUYEN, LANPHUONG (DDS)
Entity Type:Individual
Prefix:DR
First Name:LANPHUONG
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:LANNE
Other - Middle Name:
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:400 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-1020
Mailing Address - Country:US
Mailing Address - Phone:262-633-0775
Mailing Address - Fax:262-632-0925
Practice Address - Street 1:400 LAKE AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1020
Practice Address - Country:US
Practice Address - Phone:262-633-0775
Practice Address - Fax:262-632-0925
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25200151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33417100Medicaid