Basic Information
| Provider Information | |||||||||
| NPI: | 1649610247 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | PHOUNG | ||||||||
| MiddleName: | QUOC | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12626 WOODFOREST BLVD # Z | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770153425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135900999 | ||||||||
| FaxNumber: | 1735901299 | ||||||||
| Practice Location | |||||||||
| Address1: | 5225 KATY FWY STE 104 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770072268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8326730999 | ||||||||
| FaxNumber: | 2816572406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2013 | ||||||||
| LastUpdateDate: | 06/27/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 29084 | TX | Y | Dental Providers | Dentist | General Practice |
No ID Information.