Provider Demographics
NPI:1659151306
Name:PHAM, TAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:TAN
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10087 KINGLET DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-4618
Mailing Address - Country:US
Mailing Address - Phone:561-602-2490
Mailing Address - Fax:
Practice Address - Street 1:8482 PERKINS RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-1022
Practice Address - Country:US
Practice Address - Phone:225-926-4133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA74981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice