Provider Demographics
NPI:1164820130
Name:JOSEPH PHEN, DENTIST, A DENTAL CORPORATION
Entity Type:Organization
Organization Name:JOSEPH PHEN, DENTIST, A DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:PHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-691-6997
Mailing Address - Street 1:8351 ELK GROVE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-5515
Mailing Address - Country:US
Mailing Address - Phone:916-691-6997
Mailing Address - Fax:
Practice Address - Street 1:8351 ELK GROVE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-5515
Practice Address - Country:US
Practice Address - Phone:916-691-6997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45172305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1285691907OtherDENTISTRY