Provider Demographics
NPI:1184847162
Name:TRAN, PHAT (DMD)
Entity Type:Individual
Prefix:
First Name:PHAT
Middle Name:
Last Name:TRAN
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 1:13309 BROOKHURST ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-3117
Mailing Address - Country:US
Mailing Address - Phone:714-537-3769
Mailing Address - Fax:714-537-7043
Practice Address - Street 1:13309 BROOKHURST ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-3117
Practice Address - Country:US
Practice Address - Phone:714-537-3769
Practice Address - Fax:714-537-7043
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40035122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG92210-01Medicare ID - Type UnspecifiedMEDICAL PROVIDER NUMBER