Provider Demographics
NPI:1811916380
Name:PHAM, PHUONG T (DMD)
Entity type:Individual
Prefix:
First Name:PHUONG
Middle Name:T
Last Name:PHAM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 DANIELS ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-1611
Mailing Address - Country:US
Mailing Address - Phone:508-798-8525
Mailing Address - Fax:508-756-8814
Practice Address - Street 1:17 DANIELS ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-1611
Practice Address - Country:US
Practice Address - Phone:508-798-8525
Practice Address - Fax:508-756-8814
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA175491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX06354OtherBC & BS DENTAL