Provider Demographics
NPI:1245607837
Name:PHAM, MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
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 1:2801 WATERMAN BLVD STE 290
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-2972
Mailing Address - Country:US
Mailing Address - Phone:707-425-5666
Mailing Address - Fax:
Practice Address - Street 1:2801 WATERMAN BLVD STE 290
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-2972
Practice Address - Country:US
Practice Address - Phone:707-425-5666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA649871223E0200X
MND14185122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No122300000XDental ProvidersDentist