Basic Information
Provider Information
NPI: 1174592323
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PHEN
FirstName: ALFRED
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: D.D.S.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 926 LEISHA LN
Address2:  
City: REDDING
State: CA
PostalCode: 960016203
CountryCode: US
TelephoneNumber: 9167086245
FaxNumber:  
Practice Location
Address1: 1667 HILLTOP DR
Address2:  
City: REDDING
State: CA
PostalCode: 960020251
CountryCode: US
TelephoneNumber: 5302235500
FaxNumber: 5302231790
Other Information
ProviderEnumerationDate: 03/17/2006
LastUpdateDate: 02/23/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X46929CAY Dental ProvidersDentist 

No ID Information.


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