Provider Demographics
NPI:1639396260
Name:PHAM, TUAN (DDS)
Entity Type:Individual
Prefix:
First Name:TUAN
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
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:PO BOX 6950
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92412-6950
Mailing Address - Country:US
Mailing Address - Phone:909-888-7817
Mailing Address - Fax:909-888-8250
Practice Address - Street 1:164 W HOSPITALITY LN STE 14
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3329
Practice Address - Country:US
Practice Address - Phone:909-888-7817
Practice Address - Fax:909-888-5280
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA540231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice