Provider Demographics
NPI:1588624258
Name:PHAN, TARCHYA THAO (DDS)
Entity Type:Individual
Prefix:DR
First Name:TARCHYA
Middle Name:THAO
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 1:2205 VESPER CIR
Mailing Address - Street 2:SUITE-103
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3501
Mailing Address - Country:US
Mailing Address - Phone:951-737-5540
Mailing Address - Fax:951-737-5549
Practice Address - Street 1:2205 VESPER CIR
Practice Address - Street 2:SUITE-103
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3501
Practice Address - Country:US
Practice Address - Phone:951-737-5540
Practice Address - Fax:951-737-5549
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA423981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB4239801OtherDENTICAL