Provider Demographics
NPI:1376190744
Name:JENNIFER M. PHAM DMD PC
Entity Type:Organization
Organization Name:JENNIFER M. PHAM DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MINH
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:703-629-5088
Mailing Address - Street 1:42550 STIRES DR
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20152-6655
Mailing Address - Country:US
Mailing Address - Phone:703-629-5088
Mailing Address - Fax:
Practice Address - Street 1:18 WIRT ST SW
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175-2915
Practice Address - Country:US
Practice Address - Phone:703-777-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty