Basic Information
| Provider Information | |||||||||
| NPI: | 1790124220 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANSCOY-PHAM | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 122 SHADYWOOD LN | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782167334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9792367281 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4622 W COMMERCE ST STE 108 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782371608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107579913 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2013 | ||||||||
| LastUpdateDate: | 03/22/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 29017 | TX | Y | Dental Providers | Dentist | General Practice |
No ID Information.