Provider Demographics
NPI:1558343715
Name:PHAN, KHANHLAM KIM (DDS)
Entity type:Individual
Prefix:
First Name:KHANHLAM
Middle Name:KIM
Last Name:PHAN
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 1:504 16TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-4014
Mailing Address - Country:US
Mailing Address - Phone:425-505-7263
Mailing Address - Fax:
Practice Address - Street 1:137 N MONTEBELLO BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4797
Practice Address - Country:US
Practice Address - Phone:425-505-7263
Practice Address - Fax:425-505-7263
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56940122300000X, 122300000X
WADE60197084122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist