Provider Demographics
NPI:1386831550
Name:PHAM, JUSTINA SULLIVAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTINA
Middle Name:SULLIVAN
Last Name:PHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JUSTINA
Other - Middle Name:MELISSA
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2780 STATE STREET
Mailing Address - Street 2:SUITE 12
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93105
Mailing Address - Country:US
Mailing Address - Phone:805-687-1411
Mailing Address - Fax:805-687-1429
Practice Address - Street 1:2780 STATE STREET
Practice Address - Street 2:SUITE 12
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105
Practice Address - Country:US
Practice Address - Phone:805-687-1411
Practice Address - Fax:805-687-1429
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48855122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist