Provider Demographics
NPI:1801029590
Name:GINA C PHAM DDS PC
Entity Type:Organization
Organization Name:GINA C PHAM DDS PC
Other - Org Name:BRITESTARS PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:C
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-490-5050
Mailing Address - Street 1:PO BOX 10083
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-8083
Mailing Address - Country:US
Mailing Address - Phone:703-626-8196
Mailing Address - Fax:
Practice Address - Street 1:12602 LAKE RIDGE DR
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2335
Practice Address - Country:US
Practice Address - Phone:703-490-5050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-27
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014117751223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty