Provider Demographics
NPI:1679014385
Name:PHAM, KIM-VY CHANH (DMD, PLLC)
Entity Type:Individual
Prefix:
First Name:KIM-VY
Middle Name:CHANH
Last Name:PHAM
Suffix:
Gender:F
Credentials:DMD, PLLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 E FLAMINGO RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5107
Mailing Address - Country:US
Mailing Address - Phone:702-798-6684
Mailing Address - Fax:
Practice Address - Street 1:1825 E FLAMINGO RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5107
Practice Address - Country:US
Practice Address - Phone:702-798-6684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-14
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6793122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist