Provider Demographics
NPI:1154330017
Name:PHAN, CHAU MY (DENTIST)
Entity Type:Individual
Prefix:MRS
First Name:CHAU
Middle Name:MY
Last Name:PHAN
Suffix:
Gender:F
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 ALUM ROCK AVE
Mailing Address - Street 2:#30
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95127
Mailing Address - Country:US
Mailing Address - Phone:408-937-5058
Mailing Address - Fax:408-937-1309
Practice Address - Street 1:2820 ALUM ROCK AVE
Practice Address - Street 2:#30
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95127
Practice Address - Country:US
Practice Address - Phone:408-937-5058
Practice Address - Fax:408-937-1309
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA509711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA50971Medicaid