Provider Demographics
NPI:1609905850
Name:PHAN, MINDY TRIEU (DMD)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:TRIEU
Last Name:PHAN
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 1:12042 BROOKHURST ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-2815
Mailing Address - Country:US
Mailing Address - Phone:714-539-9500
Mailing Address - Fax:
Practice Address - Street 1:12042 BROOKHURST ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-2815
Practice Address - Country:US
Practice Address - Phone:714-539-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD493921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice