Provider Demographics
NPI:1306200910
Name:SHANNON PHAM & ASSOCIATES, DDS, PLLC
Entity Type:Organization
Organization Name:SHANNON PHAM & ASSOCIATES, DDS, PLLC
Other - Org Name:EMMY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:QUYNH
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:281-789-8644
Mailing Address - Street 1:11611 CARSON FIELD LN
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-2845
Mailing Address - Country:US
Mailing Address - Phone:832-273-5361
Mailing Address - Fax:
Practice Address - Street 1:20503 FM 529 RD
Practice Address - Street 2:SUITE 500
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77433-3297
Practice Address - Country:US
Practice Address - Phone:281-789-8644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-09
Last Update Date:2016-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX256461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2130130Medicaid