Provider Demographics
NPI:1093199598
Name:PHAM, ELISE (DMD)
Entity Type:Individual
Prefix:DR
First Name:ELISE
Middle Name:
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 1:30 ROSY FINCH LN
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-1814
Mailing Address - Country:US
Mailing Address - Phone:949-357-3700
Mailing Address - Fax:
Practice Address - Street 1:30 ROSY FINCH LN
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-1814
Practice Address - Country:US
Practice Address - Phone:949-357-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64724122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist