Provider Demographics
NPI:1710415716
Name:PHAN, LINH (DDS)
Entity Type:Individual
Prefix:DR
First Name:LINH
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 CRYSTAL DR APT 323
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22202-4103
Mailing Address - Country:US
Mailing Address - Phone:720-987-8321
Mailing Address - Fax:
Practice Address - Street 1:12602 LAKE RIDGE DR
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192
Practice Address - Country:US
Practice Address - Phone:703-490-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-02
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA04014162381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program