Provider Demographics
NPI:1356862908
Name:PHAN, JEFF (DMD)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 AVENUE D STE 100
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98290-2081
Mailing Address - Country:US
Mailing Address - Phone:360-568-9694
Mailing Address - Fax:
Practice Address - Street 1:1001 AVENUE D STE 100
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-2081
Practice Address - Country:US
Practice Address - Phone:360-568-9694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2022-05-12
Deactivation Date:2019-07-08
Deactivation Code:
Reactivation Date:2021-06-30
Provider Licenses
StateLicense IDTaxonomies
WA612622231223E0200X
TX372111223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics