Provider Demographics
NPI:1558577379
Name:PHAN WONG, VIVIANE VY (RDH)
Entity Type:Individual
Prefix:
First Name:VIVIANE
Middle Name:VY
Last Name:PHAN WONG
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 SOUTH PARK VICTORIA DRIVE
Mailing Address - Street 2:
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035
Mailing Address - Country:US
Mailing Address - Phone:408-262-7262
Mailing Address - Fax:408-274-7619
Practice Address - Street 1:1121 SOUTH PARK VICTORIA DRIVE
Practice Address - Street 2:
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035
Practice Address - Country:US
Practice Address - Phone:408-262-7262
Practice Address - Fax:408-274-7619
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15474124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist