Provider Demographics
NPI:1740490648
Name:NGUYEN, PHUONG NGOC (DMD)
Entity type:Individual
Prefix:
First Name:PHUONG
Middle Name:NGOC
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4585 DAISY REID AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-7802
Mailing Address - Country:US
Mailing Address - Phone:714-235-1324
Mailing Address - Fax:
Practice Address - Street 1:9328 CASTLE HILL RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22153-3900
Practice Address - Country:US
Practice Address - Phone:714-235-1324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA4014122501223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery