Provider Demographics
NPI:1811623002
Name:NGUYEN, KELLY P (DMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:P
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 RIVERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-0439
Mailing Address - Country:US
Mailing Address - Phone:817-715-1248
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?:No
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38782122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist