Provider Demographics
NPI:1275752636
Name:PHAMNGUYEN, BRYAN QUANG (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:QUANG
Last Name:PHAMNGUYEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:MR
Other - First Name:QUANG
Other - Middle Name:NGUYEN
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5908 TAMANACO TRL
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-3279
Mailing Address - Country:US
Mailing Address - Phone:407-493-1623
Mailing Address - Fax:
Practice Address - Street 1:1417 N SEMORAN BLVD
Practice Address - Street 2:STE 104
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-3555
Practice Address - Country:US
Practice Address - Phone:407-381-1200
Practice Address - Fax:407-381-9970
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL132721223G0001X
TX167921223G0001X
CA398691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice