Provider Demographics
NPI:1952455842
Name:PHAM, ROSE C (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROSE
Middle Name:C
Last Name:PHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12770 W NORTH AVE
Mailing Address - Street 2:BUILDING A
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4628
Mailing Address - Country:US
Mailing Address - Phone:262-782-6311
Mailing Address - Fax:262-782-6770
Practice Address - Street 1:12770 W NORTH AVE
Practice Address - Street 2:BUILDING A
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4628
Practice Address - Country:US
Practice Address - Phone:262-782-6311
Practice Address - Fax:262-782-6770
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WIWI 48571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice