Provider Demographics
NPI:1154479509
Name:PHAM, TAN BA (DMD)
Entity Type:Individual
Prefix:MR
First Name:TAN
Middle Name:BA
Last Name:PHAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6950 NE CAMPUS WAY
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124
Mailing Address - Country:US
Mailing Address - Phone:503-952-2164
Mailing Address - Fax:503-526-4418
Practice Address - Street 1:9609 E MILL PLAN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-3478
Practice Address - Country:US
Practice Address - Phone:360-896-3022
Practice Address - Fax:360-896-4185
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00007715122300000X
ORD7224122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist