Provider Demographics
NPI:1841289188
Name:NGUYEN, PETER PHUOC (DMD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:PHUOC
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:PHUOC
Other - Middle Name:
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:2220 W APACHE RAIN RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-5086
Mailing Address - Country:US
Mailing Address - Phone:623-907-9334
Mailing Address - Fax:
Practice Address - Street 1:7435 W LOWER BUCKEYE RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85043-7636
Practice Address - Country:US
Practice Address - Phone:623-907-9334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5995122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1841289188Medicaid