Provider Demographics
NPI:1730660929
Name:PHAN, STEVEN (DDS)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 ROCKY RIDGE DR APT 616
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3005
Mailing Address - Country:US
Mailing Address - Phone:949-636-5846
Mailing Address - Fax:
Practice Address - Street 1:26682 AVENIDA SHONTO
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-2610
Practice Address - Country:US
Practice Address - Phone:949-636-5846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101481223G0001X
CA1031961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty