Provider Demographics
NPI:1558943159
Name:NGUYEN, DINH KHOA
Entity type:Individual
Prefix:
First Name:DINH
Middle Name:KHOA
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 N DUTTON AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4606
Mailing Address - Country:US
Mailing Address - Phone:707-303-3395
Mailing Address - Fax:707-303-3181
Practice Address - Street 1:1110 N DUTTON AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4606
Practice Address - Country:US
Practice Address - Phone:707-303-3395
Practice Address - Fax:707-303-3181
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2025-12-10
Deactivation Date:2025-09-07
Deactivation Code:
Reactivation Date:2025-12-09
Provider Licenses
StateLicense IDTaxonomies
CA112256122300000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician