Provider Demographics
NPI:1194396713
Name:PHAN, VAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:VAN
Middle Name:
Last Name:PHAN
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 1:6319 JONESBORO RD STE A
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-1730
Mailing Address - Country:US
Mailing Address - Phone:770-703-4205
Mailing Address - Fax:
Practice Address - Street 1:6319 JONESBORO RD STE A
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-1730
Practice Address - Country:US
Practice Address - Phone:832-420-3772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN122378122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist