Provider Demographics
NPI:1205986221
Name:HA, KIM-PHUNG THI (DMD)
Entity type:Individual
Prefix:DR
First Name:KIM-PHUNG
Middle Name:THI
Last Name:HA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:756 E HOLT AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5628
Mailing Address - Country:US
Mailing Address - Phone:909-622-8622
Mailing Address - Fax:
Practice Address - Street 1:756 E HOLT AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5628
Practice Address - Country:US
Practice Address - Phone:909-622-8622
Practice Address - Fax:909-397-4155
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA365481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG92046OtherMEDI-CAL PROVIDER NUMBER