Provider Demographics
NPI:1295854099
Name:PHAN, SANDY (DMD)
Entity Type:Individual
Prefix:
First Name:SANDY
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2263 FAIRVIEW RD
Mailing Address - Street 2:K
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-1672
Mailing Address - Country:US
Mailing Address - Phone:949-515-9280
Mailing Address - Fax:949-515-9289
Practice Address - Street 1:2263 FAIRVIEW RD
Practice Address - Street 2:#K
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-1672
Practice Address - Country:US
Practice Address - Phone:949-515-9280
Practice Address - Fax:949-515-9289
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA489801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice