MEDICARE: LEVI QUANGLONG PHAM

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	7384	OK

General Provider Information

NPI Number	:	1356969141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEVI QUANGLONG PHAM

Provider Business Mailing Address
First Line	:	921 NE 13TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73104-5007
Country	:	US
Telephone Number	:	405-456-1000
Fax Number	:

Provider Business Practice Location Address
First Line	:	3625 NW 39TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-6309
Country	:	US
Telephone Number	:	405-253-0107
Fax Number	:

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

Provider Enumeration Date	:	07/08/2020
Last Update Date	:	09/07/2021

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