Provider Demographics
NPI:1568751568
Name:DUC PHAM DENTISTRY
Entity Type:Organization
Organization Name:DUC PHAM DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DUC
Authorized Official - Middle Name:X
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-466-1500
Mailing Address - Street 1:3610 S. COOPER ST SUITE112
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015
Mailing Address - Country:US
Mailing Address - Phone:817-466-1500
Mailing Address - Fax:
Practice Address - Street 1:3610 S. COOPER ST SUITE112
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015
Practice Address - Country:US
Practice Address - Phone:817-466-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20757122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1595548-01Medicaid