Provider Demographics
NPI:1053852319
Name:DENNIS H. PHAM DDS DENTAL CORPORATION
Entity Type:Organization
Organization Name:DENNIS H. PHAM DDS DENTAL CORPORATION
Other - Org Name:CALEO BAY ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:720-935-5704
Mailing Address - Street 1:47875 CALEO BAY DR
Mailing Address - Street 2:A101
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-6386
Mailing Address - Country:US
Mailing Address - Phone:760-564-1300
Mailing Address - Fax:
Practice Address - Street 1:47875 CALEO BAY DR
Practice Address - Street 2:A101
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-6386
Practice Address - Country:US
Practice Address - Phone:760-564-1300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1002071223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty