Provider Demographics
NPI:1659950087
Name:PHAM, JIMMY DUY
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:DUY
Last Name:PHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14852 GIVENS PL
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-5513
Mailing Address - Country:US
Mailing Address - Phone:714-487-4257
Mailing Address - Fax:
Practice Address - Street 1:21 GLEN ED PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-3333
Practice Address - Country:US
Practice Address - Phone:618-656-0608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-04
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO20220229321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program