Provider Demographics
NPI:1538122494
Name:PHAN, TIEN DINH (DMD)
Entity Type:Individual
Prefix:DR
First Name:TIEN
Middle Name:DINH
Last Name:PHAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:TIEN
Other - Middle Name:DINH
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1200 W WALNUT HILL LN
Mailing Address - Street 2:SUITE 3950
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3029
Mailing Address - Country:US
Mailing Address - Phone:972-514-1672
Mailing Address - Fax:
Practice Address - Street 1:6901 MCCART AVE
Practice Address - Street 2:SUITE 175
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-6377
Practice Address - Country:US
Practice Address - Phone:817-263-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX223341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice