Provider Demographics
NPI:1083840441
Name:PHAM, LONG P (DDS)
Entity Type:Individual
Prefix:
First Name:LONG
Middle Name:P
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 1:1300 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ROCK FALLS
Mailing Address - State:IL
Mailing Address - Zip Code:61071-1005
Mailing Address - Country:US
Mailing Address - Phone:815-626-2230
Mailing Address - Fax:815-626-6339
Practice Address - Street 1:1300 W 2ND ST
Practice Address - Street 2:
Practice Address - City:ROCK FALLS
Practice Address - State:IL
Practice Address - Zip Code:61071-1005
Practice Address - Country:US
Practice Address - Phone:815-626-2230
Practice Address - Fax:815-626-6339
Is Sole Proprietor?:No
Enumeration Date:2009-05-29
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027905122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist