Provider Demographics
NPI:1598347510
Name:COSTA MESA ORAL SURGERY
Entity Type:Organization
Organization Name:COSTA MESA ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:DUONG
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:310-849-4690
Mailing Address - Street 1:4582 KATELLA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2655
Mailing Address - Country:US
Mailing Address - Phone:310-849-4690
Mailing Address - Fax:562-598-4693
Practice Address - Street 1:2900 BRISTOL ST STE D101
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5939
Practice Address - Country:US
Practice Address - Phone:562-598-4683
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty