Provider Demographics
NPI:1457424012
Name:NGUYEN, LISA THI (DDS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:THI
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 1:2511 S CENTRAL AVE STE A
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-1634
Mailing Address - Country:US
Mailing Address - Phone:213-763-2510
Mailing Address - Fax:
Practice Address - Street 1:2511 S CENTRAL AVE STE A
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-1634
Practice Address - Country:US
Practice Address - Phone:213-763-2510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA475341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG-93842-01OtherDENTI-CAL PROVIDER NUMBER