Provider Demographics
NPI:1467604454
Name:PHAN, ANDREW KYANH (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:KYANH
Last Name:PHAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6919 SE 82ND AVE STE 103
Mailing Address - Street 2:TLC DENTISTRY
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-5873
Mailing Address - Country:US
Mailing Address - Phone:503-774-3546
Mailing Address - Fax:503-774-3547
Practice Address - Street 1:6919 SE 82ND AVE STE 103
Practice Address - Street 2:TLC DENTISTRY
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-5873
Practice Address - Country:US
Practice Address - Phone:503-774-3546
Practice Address - Fax:503-774-3547
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD64651223G0001X
CA387331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice