1306200910 NPI number — SHANNON PHAM & ASSOCIATES, DDS, PLLC

Table of content: (NPI 1306200910)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306200910 NPI number — SHANNON PHAM & ASSOCIATES, DDS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHANNON PHAM & ASSOCIATES, DDS, PLLC
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:
EMMY DENTAL
Provider Other Organization Name Type Code:
3
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:
1306200910
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11611 CARSON FIELD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CYPRESS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77433-2845
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-273-5361
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20503 FM 529 RD
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
CYPRESS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77433-3297
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-789-8644
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/09/2016

Additional Information

Authorized Official

Authorized Official Last Name:
PHAM
Authorized Official First Name:
SHANNON
Authorized Official Middle Name:
QUYNH
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
281-789-8644

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  25646 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2130130 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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