MEDICARE: DR. NAM MINH PHAN DMD

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	59073	CA

General Provider Information

NPI Number	:	1881924298
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NAM MINH PHAN DMD

Provider Business Mailing Address
First Line	:	4318 S EASTERN AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6016
Country	:	US
Telephone Number	:	310-955-0683
Fax Number	:

Provider Business Practice Location Address
First Line	:	4318 S EASTERN AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6016
Country	:	US
Telephone Number	:	310-955-0683
Fax Number	:

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

Provider Enumeration Date	:	01/07/2010
Last Update Date	:	01/02/2013

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