Provider Demographics
NPI:1710205505
Name:JORDAN PHAM DENTAL CORPORATION
Entity Type:Organization
Organization Name:JORDAN PHAM DENTAL CORPORATION
Other - Org Name:JORDAN & PHAM DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:A
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-888-5665
Mailing Address - Street 1:30212 TOMAS
Mailing Address - Street 2:SUITE 340
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688
Mailing Address - Country:US
Mailing Address - Phone:949-888-5665
Mailing Address - Fax:949-888-6835
Practice Address - Street 1:30212 TOMAS
Practice Address - Street 2:SUITE 340
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688
Practice Address - Country:US
Practice Address - Phone:949-888-5665
Practice Address - Fax:949-888-6835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51597305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service