Provider Demographics
NPI:1891279485
Name:PHAN, JUDY THI (RDH)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:THI
Last Name:PHAN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7011 LINDA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-6307
Mailing Address - Country:US
Mailing Address - Phone:858-810-8729
Mailing Address - Fax:858-987-5823
Practice Address - Street 1:7011 LINDA VISTA RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-6307
Practice Address - Country:US
Practice Address - Phone:858-810-8729
Practice Address - Fax:858-987-5823
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32230124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist