Provider Demographics
NPI:1811739527
Name:NGUYEN, DA-THAO THI (DDS)
Entity type:Individual
Prefix:DR
First Name:DA-THAO
Middle Name:THI
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1739 BROKEN BOW DR W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-3571
Mailing Address - Country:US
Mailing Address - Phone:270-320-1594
Mailing Address - Fax:
Practice Address - Street 1:6915 LONGLEAF PINE PKWY
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-7180
Practice Address - Country:US
Practice Address - Phone:270-320-1594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN289591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice