Provider Demographics
NPI:1477097046
Name:PHAN, KATINA D (DH)
Entity Type:Individual
Prefix:
First Name:KATINA
Middle Name:D
Last Name:PHAN
Suffix:
Gender:F
Credentials:DH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2670 S WHITE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-2071
Mailing Address - Country:US
Mailing Address - Phone:408-729-4290
Mailing Address - Fax:
Practice Address - Street 1:242 LA PALA DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95127-2103
Practice Address - Country:US
Practice Address - Phone:669-900-0030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-15
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26292124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist