Provider Demographics
NPI:1396864187
Name:PHAN, THOMAS TUAN (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:TUAN
Last Name:PHAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9324 WINDING BROOK WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-4091
Mailing Address - Country:US
Mailing Address - Phone:916-685-5148
Mailing Address - Fax:
Practice Address - Street 1:9184 E STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-9510
Practice Address - Country:US
Practice Address - Phone:916-686-1101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA488471223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery