Provider Demographics
NPI:1790124220
Name:VANSCOY-PHAM, JENNIFER (DDS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:VANSCOY-PHAM
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 1:122 SHADYWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-7334
Mailing Address - Country:US
Mailing Address - Phone:979-236-7281
Mailing Address - Fax:
Practice Address - Street 1:4622 W COMMERCE ST STE 108
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78237-1608
Practice Address - Country:US
Practice Address - Phone:210-757-9913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-18
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX290171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice