Provider Demographics
NPI:1003176512
Name:PHUONGDAO DMD LLC
Entity Type:Organization
Organization Name:PHUONGDAO DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHUONG
Authorized Official - Middle Name:THI
Authorized Official - Last Name:DAO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-389-8317
Mailing Address - Street 1:910 BROADWAY FL 1
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-3126
Mailing Address - Country:US
Mailing Address - Phone:617-389-8317
Mailing Address - Fax:
Practice Address - Street 1:910 BROADWAY FL 1
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-3126
Practice Address - Country:US
Practice Address - Phone:617-389-8317
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-18
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA175731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX06225OtherBLUE CROSS BLUE SHIELD
MA0276685Medicaid