Provider Demographics
NPI:1558343715
Name:PHAN, KHANHLAM KIM (DDS)
Entity Type:Individual
Prefix:DR
First Name:KHANHLAM
Middle Name:KIM
Last Name:PHAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-3926
Mailing Address - Country:US
Mailing Address - Phone:253-441-4743
Mailing Address - Fax:
Practice Address - Street 1:1202 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-3926
Practice Address - Country:US
Practice Address - Phone:425-505-7263
Practice Address - Fax:425-505-7263
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60197084122300000X, 122300000X
CA56940122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist