Provider Demographics
NPI:1780134478
Name:DR. BAO LUU NGUYEN DDS INC.
Entity type:Organization
Organization Name:DR. BAO LUU NGUYEN DDS INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BAO
Authorized Official - Middle Name:LUU
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-541-9203
Mailing Address - Street 1:21216 COLD SPRING LN
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-3440
Mailing Address - Country:US
Mailing Address - Phone:714-541-9203
Mailing Address - Fax:
Practice Address - Street 1:1125 E 17TH ST
Practice Address - Street 2:SUITE # W 127
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-2201
Practice Address - Country:US
Practice Address - Phone:714-541-9203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42378122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty