1710205505 NPI number — JORDAN PHAM DENTAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710205505 NPI number — JORDAN PHAM DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JORDAN PHAM 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:
6
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:
1710205505
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30212 TOMAS
Provider Second Line Business Mailing Address:
SUITE 340
Provider Business Mailing Address City Name:
RANCHO SANTA MARGARITA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92688
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-888-5665
Provider Business Mailing Address Fax Number:
949-888-6835

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30212 TOMAS
Provider Second Line Business Practice Location Address:
SUITE 340
Provider Business Practice Location Address City Name:
RANCHO SANTA MARGARITA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92688
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-888-5665
Provider Business Practice Location Address Fax Number:
949-888-6835
Provider Enumeration Date:
05/04/2010

Additional Information

Authorized Official

Authorized Official Last Name:
JORDAN
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
949-888-5665

Provider Taxonomy Codes

  • Taxonomy code: 305S00000X , with the licence number:  51597 , 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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