Provider Demographics
NPI:1649378886
Name:PHAN, LUONG VAN (DDS)
Entity Type:Individual
Prefix:
First Name:LUONG
Middle Name:VAN
Last Name:PHAN
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 1:837 W CHRISTOPHER ST
Mailing Address - Street 2:SUITE #A
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3761
Mailing Address - Country:US
Mailing Address - Phone:626-813-2688
Mailing Address - Fax:
Practice Address - Street 1:837 W CHRISTOPHER ST
Practice Address - Street 2:SUITE #A
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3761
Practice Address - Country:US
Practice Address - Phone:626-813-2688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA394621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice