Provider Demographics
NPI:1982357281
Name:PHAN DENTAL GROUP
Entity Type:Organization
Organization Name:PHAN DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:H. DERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:408-251-7901
Mailing Address - Street 1:150 N JACKSON AVE STE 211
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1908
Mailing Address - Country:US
Mailing Address - Phone:408-251-7901
Mailing Address - Fax:408-251-0991
Practice Address - Street 1:7048 DUBLIN BLVD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568-3017
Practice Address - Country:US
Practice Address - Phone:925-833-0535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223X0008XDental ProvidersDentistOral and Maxillofacial RadiologyGroup - Single Specialty