Provider Demographics
NPI:1003900705
Name:PHAM, KEVIN THANG I (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:THANG
Last Name:PHAM
Suffix:I
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7746 LORRAINE AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-4234
Mailing Address - Country:US
Mailing Address - Phone:209-475-0869
Mailing Address - Fax:209-475-0859
Practice Address - Street 1:7746 LORRAINE AVE STE 204
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-4234
Practice Address - Country:US
Practice Address - Phone:209-475-0869
Practice Address - Fax:209-475-0859
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA489791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice