Basic Information
| Provider Information | |||||||||
| NPI: | 1013558154 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DENTISTS OF PORT CHARLOTTE, PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DENTISTS OF PORT CHARLOTTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 17000 RED HILL AVE | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926145626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148458500 | ||||||||
| FaxNumber: | 3039520892 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 TAMIAMI TRL STE 102 | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339481121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9415848926 | ||||||||
| FaxNumber: | 9417029407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2019 | ||||||||
| LastUpdateDate: | 10/15/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PHAM | ||||||||
| AuthorizedOfficialFirstName: | MINH | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9415848926 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.