Provider Demographics
NPI:1578996286
Name:KEVIN THANG PHAM, DDS, INC.
Entity Type:Organization
Organization Name:KEVIN THANG PHAM, DDS, INC.
Other - Org Name:KEVIN THANG PHAM DDS PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:THANG
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:209-475-0869
Mailing Address - Street 1:7746 LORRAINE AVE SUITE 204
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-4234
Mailing Address - Country:US
Mailing Address - Phone:209-475-0869
Mailing Address - Fax:209-475-0859
Practice Address - Street 1:7746 LORRAINE AVE SUITE 204
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-4234
Practice Address - Country:US
Practice Address - Phone:209-475-0869
Practice Address - Fax:209-475-0859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-16
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA489791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty