Provider Demographics
NPI:1700976552
Name:PHAN, ANTHONY (DMD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6116 W FLAMINGO RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-2280
Mailing Address - Country:US
Mailing Address - Phone:702-369-5551
Mailing Address - Fax:702-367-3406
Practice Address - Street 1:445 W CRAIG RD # 121-122
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-1230
Practice Address - Country:US
Practice Address - Phone:702-399-9118
Practice Address - Fax:702-633-7420
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV49231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice