Provider Demographics
NPI:1356057723
Name:PHAM, JENEVIE (DDS)
Entity type:Individual
Prefix:DR
First Name:JENEVIE
Middle Name:
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 1:1239 N AVALON BLVD # A
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-2601
Mailing Address - Country:US
Mailing Address - Phone:714-417-8283
Mailing Address - Fax:
Practice Address - Street 1:1239 N AVALON BLVD # A
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-2601
Practice Address - Country:US
Practice Address - Phone:714-417-8283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-27
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108455122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist