Provider Demographics
NPI:1801193982
Name:PHAM, JENNIFER (DMD, MS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42550 STIRES DR
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20152-6655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:42550 STIRES DR
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20152-6655
Practice Address - Country:US
Practice Address - Phone:703-629-5088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014129941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice