Provider Demographics
NPI:1750657615
Name:NGUYEN, LIZETTE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:LIZETTE
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13910 SE GLADSTONE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-3572
Mailing Address - Country:US
Mailing Address - Phone:503-754-0175
Mailing Address - Fax:
Practice Address - Street 1:115 NE MAY LN
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-9272
Practice Address - Country:US
Practice Address - Phone:503-883-4737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH5490124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist