Provider Demographics
NPI:1700909439
Name:PHAM, JACQUELINE L (DDS)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:L
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:PO BOX 730667
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95173-0667
Mailing Address - Country:US
Mailing Address - Phone:408-223-1029
Mailing Address - Fax:408-223-1032
Practice Address - Street 1:1906 ABORN RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95121-1581
Practice Address - Country:US
Practice Address - Phone:408-223-1029
Practice Address - Fax:408-223-1032
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA434841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice