Provider Demographics
NPI:1558496174
Name:PHAN, PETER BINH (DMD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:BINH
Last Name:PHAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16229 S WESTERN AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4660
Mailing Address - Country:US
Mailing Address - Phone:408-256-3435
Mailing Address - Fax:
Practice Address - Street 1:16229 S WESTERN AVE STE 2
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247
Practice Address - Country:US
Practice Address - Phone:408-256-3435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA547221223G0001X
NV50771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA54722OtherCA DMD LICENSE
CA54722OtherCA DMD LICENSE
NVFP0137302OtherDEA #