Provider Demographics
NPI:1609096049
Name:PHAM, JACQUELINE TUYEN (DMD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:TUYEN
Last Name:PHAM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4649 BUFORD HWY
Mailing Address - Street 2:
Mailing Address - City:CHAMBLEE
Mailing Address - State:GA
Mailing Address - Zip Code:30341
Mailing Address - Country:US
Mailing Address - Phone:770-452-1400
Mailing Address - Fax:
Practice Address - Street 1:4649 BUFORD HWY
Practice Address - Street 2:
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341
Practice Address - Country:US
Practice Address - Phone:770-452-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN01125671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00787333Medicaid
GA677HOtherDORAL
GA101189OtherPEACH STATE