Provider Demographics
NPI:1114165966
Name:PHAM, JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
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 1:1515 NW LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-1748
Mailing Address - Country:US
Mailing Address - Phone:360-740-6212
Mailing Address - Fax:360-740-6222
Practice Address - Street 1:1515 NW LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-1748
Practice Address - Country:US
Practice Address - Phone:360-740-6212
Practice Address - Fax:360-740-6222
Is Sole Proprietor?:No
Enumeration Date:2009-02-02
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00008608122300000X
ORD6843122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist