Provider Demographics
NPI:1083005698
Name:AMY H. PHAM, A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:AMY H. PHAM, A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:PRODENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:H
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:530-534-6666
Mailing Address - Street 1:2630 OLIVE HWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966-6138
Mailing Address - Country:US
Mailing Address - Phone:530-534-6666
Mailing Address - Fax:530-534-1040
Practice Address - Street 1:2630 OLIVE HWY
Practice Address - Street 2:SUITE A
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95966-6138
Practice Address - Country:US
Practice Address - Phone:530-534-6666
Practice Address - Fax:530-534-1040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52451261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1174509848Medicaid