Provider Demographics
NPI:1598976029
Name:PHAN, HUY BAO
Entity Type:Individual
Prefix:DR
First Name:HUY
Middle Name:BAO
Last Name:PHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3351 TYLER AVE
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-3101
Mailing Address - Country:US
Mailing Address - Phone:626-279-5371
Mailing Address - Fax:
Practice Address - Street 1:3351 TYLER AVE
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-3101
Practice Address - Country:US
Practice Address - Phone:626-279-5371
Practice Address - Fax:626-279-5317
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2010-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD46322122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist