Basic Information
| Provider Information | |||||||||
| NPI: | 1295193746 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | VAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13442 FLOWER ST APT 5 | ||||||||
| Address2: | |||||||||
| City: | GARDEN GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928436128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146031795 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9510 HAGEMAN RD STE B | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933123953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6618292700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2016 | ||||||||
| LastUpdateDate: | 08/19/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1223G0001X | 100597 | CA | Y | Dental Providers | Dentist | General Practice |
No ID Information.