Healthcare Provider Details

I. General information

NPI: 1932486693
Provider Name (Legal Business Name): MOLAR MAGIC, LLC-COOOLIDGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2011
Last Update Date: 11/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 N ARIZONA BLVD
COOLIDGE AZ
85128-3215
US

IV. Provider business mailing address

1501 N ARIZONA BLVD
COOLIDGE AZ
85128-3215
US

V. Phone/Fax

Practice location:
  • Phone: 520-123-0077
  • Fax: 480-393-0926
Mailing address:
  • Phone: 520-123-0077
  • Fax: 480-393-0926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6854
License Number StateAZ

VIII. Authorized Official

Name: DR. THIEN CHI PHAM
Title or Position: OWNER
Credential: DDS
Phone: 520-723-0077