Provider Demographics
NPI:1801990130
Name:NGUYEN, LONG BAO (DDS)
Entity type:Individual
Prefix:MR
First Name:LONG
Middle Name:BAO
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 1:9290 SIERRA COLLEGE BOULEVARD
Mailing Address - Street 2:#300
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661
Mailing Address - Country:US
Mailing Address - Phone:916-788-8450
Mailing Address - Fax:916-788-8452
Practice Address - Street 1:9290 SIERRA COLLEGE BOULEVARD
Practice Address - Street 2:#300
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661
Practice Address - Country:US
Practice Address - Phone:916-788-8450
Practice Address - Fax:916-788-8452
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45159122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist