Provider Demographics
NPI:1851475149
Name:PHAN, VAN H (DMD)
Entity Type:Individual
Prefix:DR
First Name:VAN
Middle Name:H
Last Name:PHAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 LURLEEN WALLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35476-3249
Mailing Address - Country:US
Mailing Address - Phone:205-339-6762
Mailing Address - Fax:205-339-9103
Practice Address - Street 1:2820 LURLEEN WALLACE BLVD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35476-3249
Practice Address - Country:US
Practice Address - Phone:205-339-6762
Practice Address - Fax:205-339-9103
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL52401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice