1194491738 NPI number — MARY R PHAM DDS DENTAL CORPORATION

Table of content: (NPI 1194491738)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194491738 NPI number — MARY R PHAM DDS DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARY R PHAM DDS DENTAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1194491738
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1041 E YORBA LINDA BLVD STE 206
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLACENTIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92870-3763
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-528-8252
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12751-21771 LAKE FOREST LANE DR.
Provider Second Line Business Practice Location Address:
SUITE 21
Provider Business Practice Location Address City Name:
LAKE FOREST
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-528-8252
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/23/2021

Additional Information

Authorized Official

Authorized Official Last Name:
PHAM
Authorized Official First Name:
MARY
Authorized Official Middle Name:
REGINA
Authorized Official Title or Position:
CEO/PEDIATRIC DENTIST
Authorized Official Telephone Number:
714-528-8252

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





Copyright © 2007-2024 www.npivalidator.com