Provider Demographics
NPI:1093002321
Name:PHAM, TAM VAN
Entity Type:Individual
Prefix:
First Name:TAM
Middle Name:VAN
Last Name:PHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9922 ACACIA AVE
Mailing Address - Street 2:# 17
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92841-5261
Mailing Address - Country:US
Mailing Address - Phone:714-200-9381
Mailing Address - Fax:
Practice Address - Street 1:14221 EUCLID ST STE E
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-4991
Practice Address - Country:US
Practice Address - Phone:714-200-9381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60476122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist