Provider Demographics
NPI:1295193746
Name:PHAM, ROGER VAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:VAN
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 1:13442 FLOWER ST APT 5
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-6128
Mailing Address - Country:US
Mailing Address - Phone:714-603-1795
Mailing Address - Fax:
Practice Address - Street 1:9510 HAGEMAN RD STE B
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93312-3953
Practice Address - Country:US
Practice Address - Phone:661-829-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-28
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1005971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program