Provider Demographics
NPI:1013558154
Name:DENTISTS OF PORT CHARLOTTE, PA
Entity Type:Organization
Organization Name:DENTISTS OF PORT CHARLOTTE, PA
Other - Org Name:DENTISTS OF PORT CHARLOTTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MINH
Authorized Official - Middle Name:B
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:941-584-8926
Mailing Address - Street 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:714-845-8500
Mailing Address - Fax:303-952-0892
Practice Address - Street 1:1720 TAMIAMI TRL STE 102
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-1121
Practice Address - Country:US
Practice Address - Phone:941-584-8926
Practice Address - Fax:941-702-9407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-30
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty