Provider Demographics
NPI:1114050200
Name:PHAN, THI BINH
Entity Type:Individual
Prefix:
First Name:THI
Middle Name:BINH
Last Name:PHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TIMOTHY
Other - Middle Name:B
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:37 SANCTUARY STREET
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620
Mailing Address - Country:US
Mailing Address - Phone:714-309-2383
Mailing Address - Fax:949-262-0204
Practice Address - Street 1:1540 FERN ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-1521
Practice Address - Country:US
Practice Address - Phone:619-236-9549
Practice Address - Fax:619-234-0311
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA404841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice