Basic Information
| Provider Information | |||||||||
| NPI: | 1023184033 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7012 NE 40TH STREET | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986613052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602545254 | ||||||||
| FaxNumber: | 3609443835 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 NE 134TH STREET | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986852747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605465208 | ||||||||
| FaxNumber: | 3605742878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DE00009152 | WA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 5038997 | 05 | WA | MEDICAID | 8932838 | 01 | WA | CRIME VICTIMS | OTHER | 0158866 | 01 | WA | LABOR & INDUSTRIES | OTHER |