Provider Demographics
NPI:1134508971
Name:PHAM, TRANG (DDS)
Entity Type:Individual
Prefix:
First Name:TRANG
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 PACIFIC AVE SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-2065
Mailing Address - Country:US
Mailing Address - Phone:360-556-6040
Mailing Address - Fax:
Practice Address - Street 1:2415 PACIFIC AVE SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-2065
Practice Address - Country:US
Practice Address - Phone:360-556-6040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-27
Last Update Date:2015-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA629471223G0001X, 1223P0221X
WADE605767621223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice