Provider Demographics
NPI:1801027016
Name:PHAM, THAO KIM (DDS)
Entity Type:Individual
Prefix:
First Name:THAO
Middle Name:KIM
Last Name: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 1:161 HOUSTON AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-7089
Mailing Address - Country:US
Mailing Address - Phone:559-355-3914
Mailing Address - Fax:
Practice Address - Street 1:2950 N FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-1123
Practice Address - Country:US
Practice Address - Phone:559-355-3914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-05
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58612122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice