Provider Demographics
NPI:1407186562
Name:PHAN, THE TAI (DDS, MD)
Entity Type:Individual
Prefix:
First Name:THE
Middle Name:TAI
Last Name:PHAN
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CYMBIDIUM CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-2266
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11200 CORBIN AVE
Practice Address - Street 2:SUITE #208
Practice Address - City:PORTER RANCH
Practice Address - State:CA
Practice Address - Zip Code:91326-4120
Practice Address - Country:US
Practice Address - Phone:818-368-8522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-12
Last Update Date:2012-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA554271223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery