Provider Demographics
NPI:1245828219
Name:DERICK PHAM DMD, INC
Entity type:Organization
Organization Name:DERICK PHAM DMD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:631-693-9040
Mailing Address - Street 1:3612 FLORISTA ST
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2423
Mailing Address - Country:US
Mailing Address - Phone:562-598-4207
Mailing Address - Fax:
Practice Address - Street 1:3612 FLORISTA ST
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2423
Practice Address - Country:US
Practice Address - Phone:562-598-4207
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty