MEDICARE: MARY R. PHAM, D.D.S., INC.

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
2	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1164986220
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY R. PHAM, D.D.S., INC.

Provider Business Mailing Address
First Line	:	2750 HARBOR BLVD # B-06
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92626-5121
Country	:	US
Telephone Number	:	334-657-7668
Fax Number	:

Provider Business Practice Location Address
First Line	:	2750 HARBOR BLVD # B-06
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92626-5121
Country	:	US
Telephone Number	:	334-657-7668
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. PAUL PHAM
Credential	:	PHARMD.
Telephone Number	:	334-657-7668

Provider Enumeration Date	:	01/23/2019
Last Update Date	:	01/23/2019

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