MEDICARE: DAWNA PHAN PROFESSIONAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	5483	NV

General Provider Information

NPI Number	:	1013245695
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAWNA PHAN PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	5061 E SAHARA AVE
Second Line	:	1A
City	:	LAS VEGAS
State	:	NV
Zip	:	89142-2984
Country	:	US
Telephone Number	:	702-641-8868
Fax Number	:	702-641-8865

Provider Business Practice Location Address
First Line	:	5061 E SAHARA AVE
Second Line	:	1A
City	:	LAS VEGAS
State	:	NV
Zip	:	89142-2984
Country	:	US
Telephone Number	:	702-641-8868
Fax Number	:	702-641-8865

Authorized Official
Title or Position	:	CEO
Name	:	DR. DAWNA PHAN
Credential	:	D.M.D.
Telephone Number	:	714-728-0178

Provider Enumeration Date	:	11/19/2009
Last Update Date	:	12/22/2009

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