Provider Demographics
NPI:1235231481
Name:PHAM, LAN THANH (DDS)
Entity Type:Individual
Prefix:MR
First Name:LAN
Middle Name:THANH
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 1:1900 BRANDIE ELAINE AVE
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078
Mailing Address - Country:US
Mailing Address - Phone:770-736-7619
Mailing Address - Fax:
Practice Address - Street 1:5775 JIMMY CARTER BLVD
Practice Address - Street 2:GOOD CARE DENTAL STE 440
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071
Practice Address - Country:US
Practice Address - Phone:770-447-4702
Practice Address - Fax:770-447-4705
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA121441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice