Provider Demographics
NPI:1881824217
Name:NGUYEN, MARY (PEDIATRIC DENTIST)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:PEDIATRIC DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 RAMBLE LN APT 2336
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-0019
Mailing Address - Country:US
Mailing Address - Phone:517-862-7670
Mailing Address - Fax:
Practice Address - Street 1:3401 GREENBRIAR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-4652
Practice Address - Country:US
Practice Address - Phone:432-682-1614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS040043122300000X, 1223P0221X
MI2901020082122300000X
TX322011223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist