Provider Demographics
NPI:1023001922
Name:PHAM, DERYCK (DDS)
Entity Type:Individual
Prefix:DR
First Name:DERYCK
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:447 S SHORE RD
Mailing Address - Street 2:
Mailing Address - City:MARMORA
Mailing Address - State:NJ
Mailing Address - Zip Code:08223-1292
Mailing Address - Country:US
Mailing Address - Phone:609-390-0111
Mailing Address - Fax:
Practice Address - Street 1:447 S SHORE RD
Practice Address - Street 2:
Practice Address - City:MARMORA
Practice Address - State:NJ
Practice Address - Zip Code:08223-1292
Practice Address - Country:US
Practice Address - Phone:609-390-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052396-1122300000X
NJ02355500122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist