Provider Demographics
NPI:1477170629
Name:NGUYEN, JESSICA TIEN THUY
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:TIEN THUY
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 1:1190 POLO CLUB RD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MN
Mailing Address - Zip Code:55359-9234
Mailing Address - Country:US
Mailing Address - Phone:763-267-9671
Mailing Address - Fax:
Practice Address - Street 1:107 12TH ST SW STE 2
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-1467
Practice Address - Country:US
Practice Address - Phone:651-964-2013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11410122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist