Provider Demographics
NPI:1225113897
Name:PHAM, QUYEN MANH (DDS)
Entity Type:Individual
Prefix:
First Name:QUYEN
Middle Name:MANH
Last Name:PHAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3375 E TROPICANA AVE
Mailing Address - Street 2:SUITE F-8
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-7388
Mailing Address - Country:US
Mailing Address - Phone:702-964-3626
Mailing Address - Fax:702-425-9491
Practice Address - Street 1:3375 E TROPICANA AVE
Practice Address - Street 2:STE F-8
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-7388
Practice Address - Country:US
Practice Address - Phone:702-964-3626
Practice Address - Fax:702-425-9491
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46925122300000X
NV5042122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist