MEDICARE: JOHN C PHAM DMD 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	122300000X	Dentist	51988	CA

General Provider Information

NPI Number	:	1588914717
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN C PHAM DMD INC

Provider Business Mailing Address
First Line	:	2209 SAN GABRIEL BLVD
Second Line	:	STE A
City	:	ROSEMEAD
State	:	CA
Zip	:	91770-3664
Country	:	US
Telephone Number	:	626-288-6488
Fax Number	:

Provider Business Practice Location Address
First Line	:	2209 SAN GABRIEL BLVD
Second Line	:	STE A
City	:	ROSEMEAD
State	:	CA
Zip	:	91770-3664
Country	:	US
Telephone Number	:	626-288-6488
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOHN CUONG PHAM
Credential	:	DMD
Telephone Number	:	626-288-6488

Provider Enumeration Date	:	09/14/2012
Last Update Date	:	09/14/2012

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