Provider Demographics
NPI:1376290825
Name:CHRISTOPHER CUONG PHAM DDS A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:CHRISTOPHER CUONG PHAM DDS A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:MCKENNA
Authorized Official - Last Name:SHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-724-0845
Mailing Address - Street 1:1415 RIDGEBACK RD STE 23
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-6990
Mailing Address - Country:US
Mailing Address - Phone:619-421-2155
Mailing Address - Fax:
Practice Address - Street 1:2987 CORONADO AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-2180
Practice Address - Country:US
Practice Address - Phone:619-421-2155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-04
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty