Provider Demographics
NPI:1972548998
Name:NGUYEN, PHUC VAN (DDS)
Entity Type:Individual
Prefix:
First Name:PHUC
Middle Name:VAN
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 E SANTA CLARA STREET
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-1903
Mailing Address - Country:US
Mailing Address - Phone:408-288-9033
Mailing Address - Fax:408-288-9034
Practice Address - Street 1:650 E SANTA CLARA STREET
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-1903
Practice Address - Country:US
Practice Address - Phone:408-288-9033
Practice Address - Fax:408-288-9034
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30274122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB30274Medicaid