Provider Demographics
NPI:1710947494
Name:PHAM, IAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18791 SW BOONES FERRY RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8412
Mailing Address - Country:US
Mailing Address - Phone:503-692-6552
Mailing Address - Fax:503-692-1452
Practice Address - Street 1:18791 SW BOONES FERRY RD
Practice Address - Street 2:SUITE 3
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8412
Practice Address - Country:US
Practice Address - Phone:503-692-6552
Practice Address - Fax:503-692-1452
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD78081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORD7808OtherSTATE LICENSE
ORD7808OtherSTATE LICENSE