Basic Information
| Provider Information | |||||||||
| NPI: | 1245643154 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | MAI | ||||||||
| MiddleName: | |||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2414 S FAIRVIEW ST | ||||||||
| Address2: | SUITE #101 | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927045318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146174294 | ||||||||
| FaxNumber: | 7142424070 | ||||||||
| Practice Location | |||||||||
| Address1: | 2414 S FAIRVIEW ST | ||||||||
| Address2: | SUITE #101 | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927045318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812982433 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2014 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 29878 | TX | N | Dental Providers | Dentist | 1223G0001X | 64449 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.