Provider Demographics
NPI:1770256398
Name:MA, SELENA NGUYEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SELENA
Middle Name:NGUYEN
Last Name:MA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:SELENA
Other - Middle Name:THAO
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3225 N GRAPEVINE MILLS BLVD APT 1222
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-0976
Mailing Address - Country:US
Mailing Address - Phone:662-523-1178
Mailing Address - Fax:
Practice Address - Street 1:5800 N TARRANT PKWY STE 102
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-8003
Practice Address - Country:US
Practice Address - Phone:817-581-6453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-29
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX379411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice