Provider Demographics
NPI:1356499560
Name:PHUNG K PHAM DDS INC
Entity Type:Organization
Organization Name:PHUNG K PHAM DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PHUNG
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-227-5239
Mailing Address - Street 1:1727 N FRESNO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93703-3031
Mailing Address - Country:US
Mailing Address - Phone:559-227-5239
Mailing Address - Fax:559-227-9262
Practice Address - Street 1:1727 N FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-3031
Practice Address - Country:US
Practice Address - Phone:559-227-5239
Practice Address - Fax:559-227-9262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-07
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA524531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD52453OtherRENDERING PROVIDER NUMBER
CAG94117-01OtherBILLING PROVIDER NUMBER