Basic Information
Provider Information | |||||||||
NPI: | 1588371736 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KHOI | ||||||||
FirstName: | JONATHAN | ||||||||
MiddleName: | NGUYEN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NGUYEN | ||||||||
OtherFirstName: | JONATHAN | ||||||||
OtherMiddleName: | ANH KHOI | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 925 TIERRA LN | ||||||||
Address2: |   | ||||||||
City: | PALM SPRINGS | ||||||||
State: | CA | ||||||||
PostalCode: | 922621205 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4088384149 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5001 E RAMON RD STE 104 | ||||||||
Address2: |   | ||||||||
City: | PALM SPRINGS | ||||||||
State: | CA | ||||||||
PostalCode: | 922641544 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7602837999 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/27/2022 | ||||||||
LastUpdateDate: | 10/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 108315 | CA | Y |   | Dental Providers | Dentist |   |
No ID Information.