Provider Demographics
NPI:1518554641
Name:MARY PHAM IKEDA DENTAL CORPORATION
Entity Type:Organization
Organization Name:MARY PHAM IKEDA DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:REGINA
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:714-528-8252
Mailing Address - Street 1:2750 HARBOR BLVD STE B6
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5121
Mailing Address - Country:US
Mailing Address - Phone:714-528-8252
Mailing Address - Fax:
Practice Address - Street 1:13047 ARTESIA BLVD STE C100
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-1369
Practice Address - Country:US
Practice Address - Phone:714-528-8252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty