Provider Demographics
NPI:1093373920
Name:PHAM, THAO PHUONG (DMD)
Entity Type:Individual
Prefix:DR
First Name:THAO
Middle Name:PHUONG
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 1:5395 JIMMY CARTER BLVD # 700-A
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-1502
Mailing Address - Country:US
Mailing Address - Phone:770-559-3932
Mailing Address - Fax:
Practice Address - Street 1:3979 BUFORD HWY NE STE 122
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-1683
Practice Address - Country:US
Practice Address - Phone:470-702-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015848122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist