Provider Demographics
NPI:1356457816
Name:PHAM, LIENG T (DDS)
Entity Type:Individual
Prefix:
First Name:LIENG
Middle Name:T
Last Name:PHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 A ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-2021
Mailing Address - Country:US
Mailing Address - Phone:970-352-0048
Mailing Address - Fax:970-352-1120
Practice Address - Street 1:2930 11TH AVE
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:CO
Practice Address - Zip Code:80620-1011
Practice Address - Country:US
Practice Address - Phone:970-350-4606
Practice Address - Fax:970-350-4626
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7305122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02073054Medicaid