Provider Demographics
NPI:1134411077
Name:NGUYEN, DIANA (DDS)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9450 SCRANTON RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-4720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9450 SCRANTON RD
Practice Address - Street 2:SUITE 110
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-4720
Practice Address - Country:US
Practice Address - Phone:858-490-4281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-11
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA619041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program