Provider Demographics
NPI:1508353731
Name:PHAM, HUNG QUOC
Entity Type:Individual
Prefix:
First Name:HUNG
Middle Name:QUOC
Last Name:PHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2263 W AUGUST FARMS CIR
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-6044
Mailing Address - Country:US
Mailing Address - Phone:385-202-9721
Mailing Address - Fax:
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:385-202-9721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-13
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT11263872-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program