Provider Demographics
NPI:1245643154
Name:PHAM, MAI (DMD)
Entity type:Individual
Prefix:
First Name:MAI
Middle Name:
Last Name:PHAM
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 1:2414 S FAIRVIEW ST
Mailing Address - Street 2:SUITE #101
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-5318
Mailing Address - Country:US
Mailing Address - Phone:714-617-4294
Mailing Address - Fax:714-242-4070
Practice Address - Street 1:2414 S FAIRVIEW ST
Practice Address - Street 2:SUITE #101
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-5318
Practice Address - Country:US
Practice Address - Phone:281-298-2433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-09
Last Update Date:2024-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29878122300000X
CA644491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentist