Provider Demographics
NPI:1770840340
Name:DIEP PHAM DDS, INC
Entity Type:Organization
Organization Name:DIEP PHAM DDS, INC
Other - Org Name:GULF COAST DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIEP
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-208-2016
Mailing Address - Street 1:PO BOX 2086
Mailing Address - Street 2:
Mailing Address - City:ALIEF
Mailing Address - State:TX
Mailing Address - Zip Code:77411-2086
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:309 GARLAND DR
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-6238
Practice Address - Country:US
Practice Address - Phone:979-480-9300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIEP PHAM DDS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-19
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX178621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty