MEDICARE: DR. NHUNG THI PHAN 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	122300000X	Dentist	4270	SC

General Provider Information

NPI Number	:	1821165507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NHUNG THI PHAN D.M.D.

Provider Business Mailing Address
First Line	:	1365 BROADCLOTH ST STE 204
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29715-4507
Country	:	US
Telephone Number	:	803-548-8858
Fax Number	:	803-548-8860

Provider Business Practice Location Address
First Line	:	1365 BROADCLOTH ST STE 204
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29715-4507
Country	:	US
Telephone Number	:	803-548-8858
Fax Number	:	803-548-8860

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

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	05/24/2019

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