Provider Demographics
NPI:1881865624
Name:PHAN, VANESSA (DMD)
Entity Type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:
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 1:3596 HILL STREET
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021
Mailing Address - Country:US
Mailing Address - Phone:404-499-2216
Mailing Address - Fax:
Practice Address - Street 1:3596 HILL STREET
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:GA
Practice Address - Zip Code:30021
Practice Address - Country:US
Practice Address - Phone:404-499-2216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0121281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice