Provider Demographics
NPI:1518958248
Name:PHAM, JACOB H (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:H
Last Name:PHAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6212 PETERS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-4026
Mailing Address - Country:US
Mailing Address - Phone:540-563-0519
Mailing Address - Fax:540-563-1184
Practice Address - Street 1:6212 PETERS CREEK RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-4026
Practice Address - Country:US
Practice Address - Phone:540-563-0519
Practice Address - Fax:540-563-1184
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401413420122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice