MEDICARE: KRYSTAL PHAM DDS, 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	261QD0000X	Dental Clinic/Center	57473	CA

General Provider Information

NPI Number	:	1245559624
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KRYSTAL PHAM DDS, INC.

Provider Business Mailing Address
First Line	:	16052 BEACH BLVD STE 112
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-3842
Country	:	US
Telephone Number	:	714-841-0203
Fax Number	:	714-842-0618

Provider Business Practice Location Address
First Line	:	16052 BEACH BLVD STE 112
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-3842
Country	:	US
Telephone Number	:	714-841-0203
Fax Number	:	714-842-0618

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KRYSTAL H PHAM
Credential	:	D.D.S.
Telephone Number	:	714-841-0203

Provider Enumeration Date	:	05/24/2010
Last Update Date	:	05/24/2010

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