Provider Demographics
NPI:1811623283
Name:DERRICK PHAM DDS PROFESSIONAL CORPORATION DBA LV DENTAL
Entity Type:Organization
Organization Name:DERRICK PHAM DDS PROFESSIONAL CORPORATION DBA LV DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-417-0246
Mailing Address - Street 1:4705 S DURANGO DR STE 115
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-8162
Mailing Address - Country:US
Mailing Address - Phone:714-417-0246
Mailing Address - Fax:
Practice Address - Street 1:4705 S DURANGO DR STE 115
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-8162
Practice Address - Country:US
Practice Address - Phone:714-417-0246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty