Provider Demographics
NPI:1992835235
Name:PHAM, JACKLINE ANH-DAO (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACKLINE
Middle Name:ANH-DAO
Last Name:PHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4344 CONVOY STREET
Mailing Address - Street 2:SUITE S
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111
Mailing Address - Country:US
Mailing Address - Phone:858-616-6468
Mailing Address - Fax:858-616-6478
Practice Address - Street 1:4344 CONVOY STREET
Practice Address - Street 2:SUITE S
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111
Practice Address - Country:US
Practice Address - Phone:858-616-6468
Practice Address - Fax:858-616-6478
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA453091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice