Provider Demographics
NPI:1881017812
Name:PETER D.NGUYEN, DDS, PROFESSIONAL DENTAL CORP
Entity type:Organization
Organization Name:PETER D.NGUYEN, DDS, PROFESSIONAL DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:DINH
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:408-888-1787
Mailing Address - Street 1:3415 AMBUM AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-2802
Mailing Address - Country:US
Mailing Address - Phone:408-888-1787
Mailing Address - Fax:
Practice Address - Street 1:88 TULLY RD STE 112
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95111-1923
Practice Address - Country:US
Practice Address - Phone:408-888-1787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58300122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty