Provider Demographics
NPI:1689909376
Name:PHUNG, MONYA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MONYA
Middle Name:
Last Name:PHUNG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 W CAMPBELL AVE APT 2044
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4912
Mailing Address - Country:US
Mailing Address - Phone:503-505-3381
Mailing Address - Fax:
Practice Address - Street 1:475 E BELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-2348
Practice Address - Country:US
Practice Address - Phone:503-505-3381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60103998122300000X
AZD-79791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist