1023632676 NPI number — DERRICK ANH VO PHAM DENTAL STUDENT

Table of content: DERRICK ANH VO PHAM DENTAL STUDENT (NPI 1023632676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023632676 NPI number — DERRICK ANH VO PHAM DENTAL STUDENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHAM
Provider First Name:
DERRICK
Provider Middle Name:
ANH VO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DENTAL STUDENT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023632676
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4270 KIRKCALDY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92111-3621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-999-1299
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
92055 14TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCEANSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-725-5870
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/29/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: 106380 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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