MEDICARE: THANH PHAM D.M.D.

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	1223G0001X	General Practice Dentistry	PENDING	ME
2	1223G0001X	General Practice Dentistry	DN1855283	MA
3	122300000X	Dentist	DN1855283	MA

General Provider Information

NPI Number	:	1063649267
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THANH PHAM D.M.D.

Provider Business Mailing Address
First Line	:	88 ANGELL ST
Second Line	:
City	:	MANSFIELD
State	:	MA
Zip	:	02048-1449
Country	:	US
Telephone Number	:	617-470-0902
Fax Number	:	207-853-6180

Provider Business Practice Location Address
First Line	:	127 HIGH ST
Second Line	:
City	:	CLINTON
State	:	MA
Zip	:	01510-2510
Country	:	US
Telephone Number	:	617-470-0902
Fax Number	:	207-853-6180

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2009
Last Update Date	:	04/28/2010

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