Provider Demographics
NPI:1861554198
Name:NGUYEN, THANH NAM (DDS)
Entity type:Individual
Prefix:
First Name:THANH
Middle Name:NAM
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 1:11001 FONDREN ROAD
Mailing Address - Street 2:SUITE B
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77096
Mailing Address - Country:US
Mailing Address - Phone:713-773-9800
Mailing Address - Fax:713-773-9804
Practice Address - Street 1:11001 FONDREN ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77096
Practice Address - Country:US
Practice Address - Phone:713-773-9800
Practice Address - Fax:713-773-9804
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17532122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1891854154Medicaid
TX1831258508Medicaid
TX1861554198Medicaid