Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0004X | Dentist Anesthesiologist | 2901601178 | MI |
NPI | 1538633813 |
---|---|
Provider Name | Cuong Phu Nguyen |
First Address | Ronkonkoma, NY 11779-2792 |
Second Address | Stony Brook, NY 11794-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/01/2019 |
Last Update Date | 06/01/2022 |