Provider Demographics
NPI:1104283613
Name:NGUYEN, KELLEY
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 HEMLOCK AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3540
Mailing Address - Country:US
Mailing Address - Phone:408-646-8233
Mailing Address - Fax:
Practice Address - Street 1:581 FOSTER CITY BLVD
Practice Address - Street 2:
Practice Address - City:FOSTER CITY
Practice Address - State:CA
Practice Address - Zip Code:94404-1695
Practice Address - Country:US
Practice Address - Phone:650-286-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1005651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty