Provider Demographics
NPI:1326309329
Name:MARY REGINA PHAM D.D.S., M.S. DENTAL CORPORATION
Entity Type:Organization
Organization Name:MARY REGINA PHAM D.D.S., M.S. DENTAL CORPORATION
Other - Org Name:LOLLIPOP PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:REGINA
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:714-528-8252
Mailing Address - Street 1:1041 E YORBA LINDA BLVD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-3728
Mailing Address - Country:US
Mailing Address - Phone:714-528-8252
Mailing Address - Fax:
Practice Address - Street 1:1041 E YORBA LINDA BLVD
Practice Address - Street 2:SUITE 206
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-3728
Practice Address - Country:US
Practice Address - Phone:714-528-8252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-06
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA602221223P0221X
CA584041223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty