Provider Demographics
NPI:1851088306
Name:PHAM, JONATHAN (DMD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7543 HESPERIA AVE
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-3242
Mailing Address - Country:US
Mailing Address - Phone:818-651-4723
Mailing Address - Fax:
Practice Address - Street 1:7543 HESPERIA AVE
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-3242
Practice Address - Country:US
Practice Address - Phone:818-651-4723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-24
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108954122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist