Provider Demographics
NPI:1326241928
Name:PHAN, AIDAN N (DDS, MD)
Entity Type:Individual
Prefix:
First Name:AIDAN
Middle Name:N
Last Name:PHAN
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3610 SHIRE BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082
Mailing Address - Country:US
Mailing Address - Phone:214-572-8633
Mailing Address - Fax:214-572-8638
Practice Address - Street 1:3610 SHIRE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082
Practice Address - Country:US
Practice Address - Phone:214-572-8633
Practice Address - Fax:214-572-8638
Is Sole Proprietor?:No
Enumeration Date:2007-06-09
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23584204E00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
BP1-0022848OtherINSTITUTIONAL PERMIT