Provider Demographics
NPI:1780764316
Name:NGUYEN, KY PHUC (DDS)
Entity type:Individual
Prefix:DR
First Name:KY
Middle Name:PHUC
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3435 LEBON DR
Mailing Address - Street 2:APT 1132
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-5246
Mailing Address - Country:US
Mailing Address - Phone:951-333-3546
Mailing Address - Fax:760-732-5820
Practice Address - Street 1:240 MAIN ST # 200
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-6008
Practice Address - Country:US
Practice Address - Phone:760-732-3566
Practice Address - Fax:760-732-5820
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49618122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist