Provider Demographics
NPI:1972171866
Name:PHAM, SHAWN LOU (DDS)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:LOU
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 1:650 DUVALL AVE NE APT R1323
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98059-4775
Mailing Address - Country:US
Mailing Address - Phone:253-222-9269
Mailing Address - Fax:
Practice Address - Street 1:14212 AMBAUM BLVD SW STE 1
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-1437
Practice Address - Country:US
Practice Address - Phone:206-343-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADENT.DE.61184555122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist