Provider Demographics
NPI:1740517465
Name:PHAM, TUNG CAO
Entity type:Individual
Prefix:
First Name:TUNG
Middle Name:CAO
Last Name:PHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1824 STRAWBERRY RD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77502-2610
Mailing Address - Country:US
Mailing Address - Phone:713-477-3858
Mailing Address - Fax:
Practice Address - Street 1:1824 STRAWBERRY RD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77502-2610
Practice Address - Country:US
Practice Address - Phone:713-477-3858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-17
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00250891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTPI 206738101Medicaid