Provider Demographics
NPI:1891931762
Name:PHAM, BENNIE VAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BENNIE
Middle Name:VAN
Last Name:PHAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8981 ACACIA AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92841-4613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18426 BROOKHURST ST STE 101
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6777
Practice Address - Country:US
Practice Address - Phone:714-965-5255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-26
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054267122300000X
CA58021122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY054267OtherNY STATE DENTAL LICENSE
CA58021OtherCA STATE DENTAL LICENSE