Provider Demographics
NPI:1023184033
Name:PHAM, KRISTINE H (DMD)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:H
Last Name:PHAM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7012 NE 40TH STREET
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-3052
Mailing Address - Country:US
Mailing Address - Phone:360-254-5254
Mailing Address - Fax:360-944-3835
Practice Address - Street 1:1300 NE 134TH STREET
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-2747
Practice Address - Country:US
Practice Address - Phone:360-546-5208
Practice Address - Fax:360-574-2878
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000091521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5038997Medicaid
WA8932838OtherCRIME VICTIMS
WA0158866OtherLABOR & INDUSTRIES