Provider Demographics
NPI:1790110674
Name:VONGCHANPHEN, BRIAN (DDS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:VONGCHANPHEN
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 1:59-072 KUMUPALI RD
Mailing Address - Street 2:
Mailing Address - City:HALEIWA
Mailing Address - State:HI
Mailing Address - Zip Code:96712-9667
Mailing Address - Country:US
Mailing Address - Phone:808-398-4339
Mailing Address - Fax:
Practice Address - Street 1:810 KILANI AVE
Practice Address - Street 2:#A
Practice Address - City:WAHIAWA
Practice Address - State:HI
Practice Address - Zip Code:96786
Practice Address - Country:US
Practice Address - Phone:808-621-8281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-10
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA629121223G0001X
HIDT-26951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice