Provider Demographics
NPI:1255585162
Name:PHAM, KIM N (DMD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:N
Last Name:PHAM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MRS
Other - First Name:KIM
Other - Middle Name:PHAM
Other - Last Name:YUAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:32610 SPUN COTTON DR
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:CA
Mailing Address - Zip Code:92596-8669
Mailing Address - Country:US
Mailing Address - Phone:951-325-8805
Mailing Address - Fax:951-325-8805
Practice Address - Street 1:2205 VESPER CIR
Practice Address - Street 2:#103
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3501
Practice Address - Country:US
Practice Address - Phone:951-737-5540
Practice Address - Fax:951-737-5549
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA524521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice