Provider Demographics
NPI:1710211958
Name:NGHIEM, QUAN (DMD)
Entity type:Individual
Prefix:DR
First Name:QUAN
Middle Name:
Last Name:NGHIEM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021-1366
Mailing Address - Country:US
Mailing Address - Phone:781-888-2415
Mailing Address - Fax:
Practice Address - Street 1:1510 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-1327
Practice Address - Country:US
Practice Address - Phone:781-288-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA223121223G0001X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA46-4210597Medicaid